Clinical audit is a quality improvement process that seeks to

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					Title                   : Clinical Effectiveness and Audit
                          Annual Report 2006-07
Author of Document      : Steve Mainwaring, Clinical Effectiveness & Audit
Date of Document        : 15 August 2007
Action Required         : For information
Summary of              : Review of clinical effectiveness and audit strategy,
Document                activity and outcomes April 2006-March 2007


Clinical audit is a quality improvement process that seeks to improve patient
care and outcomes through systematic review of care against explicit criteria
and the implementation of change.

The RNHRD’s strategic priorities include the determination to provide
excellent local services that are high quality and appropriate for the needs of
our local population, and be at the leading edge in our specialised services.
We are therefore committed to clinical effectiveness and audit, evidence-
based medicine, monitoring practice and continuously improving standards.
We regularly have significant input to clinical guidelines developed by national
professional bodies and bodies such as the National Institute for Health and
Clinical Excellence (NICE), the British Society for Rheumatology (BSR) and
the Arthritis and Musculoskeletal Alliance (ARMA), and structures are in place
to ensure that we audit against any guidelines relevant to this trust and satisfy
the requirements demanded by the Annual Health Check and the Clinical
Negligence Scheme For Trusts. Evidence-based integrated care pathways
are developed here with a clinical audit component built into them in order to
achieve continuous monitoring and routine auditing.

The Clinical Effectiveness and Audit Steering Group meets bi-monthly and is
chaired by the Medical Director/the Director Governance and Performance. It
includes representatives of each specialty, Director of Nursing, Clinical
Practice Co-ordinator, Clinical Effectiveness and Audit Facilitator, PALs
Officer and Medical Records Manager. The group is responsible for
facilitating, planning, and monitoring all aspects of clinical effectiveness and
audit within the Trust across all specialties and disciplines, and ensuring that
mandatory audits such as those checking adherence to NICE guidelines and
National Service Frameworks are carried out. The list of clinical audit and
effectiveness projects in the Trust at April 2007 included seventy six
mandatory projects and thirty six arising from clinicians’ own interests. This
group also approves an annual plan which sets out the Trust’s key objectives
for clinical effectiveness and audit and then monitors compliance with them.
For instance, they include “To ensure all clinical staff and managers have an
appropriate basic awareness of the importance of Clinical Effectiveness &
Audit and how all elements operate within the RNHRD”, to which end this
area is always covered as part of the orientation day for new staff and I have

a personal introductory meeting with new medical staff as part of their
induction, “To focus clinical effectiveness and audit activity on identified
national and local clinical priority areas of concern” – the steering group
identifies national and local priorities and allocates responsibility for
completion of audits – and “To ensure staff from RNHRD contribute where
appropriate to National Guidelines”; some examples of this are in the following

The Trust contributes to evidence-based medicine on a national scale. In the
last year consultants have been involved in projects such as the BSR group
looking at anti-TNF drugs, the ARMA standards for bone diseases, and
setting up a national pain network. Nurses here have contributed to the ARMA
standards of care for connective tissue diseases and the Royal College of
Nursing guidance for telephone advice lines for people with long term
conditions and one of our nursing staff is the British Health Professionals in
Rheumatology (BHPR) representative in the BSR/BHPR standards,
guidelines and audit working group. Members of our chronic fatigue
syndrome/ME team in different professions have contributed to the
forthcoming NICE guidelines for management of that condition for adults and
for children. I am a member of a NICE external group which appraises audit
criteria for new guidelines before they are published.

My post includes assisting staff to perform high quality audits. I am involved in
the hospital’s educational programmes and give staff members advice and
guidance about their individual projects. All staff joining the trust routinely get
an introductory session about clinical effectiveness and audit. I am also a
member of individual specialties’ clinical quality groups.

This report provides below a selection of the clinical audit and effectiveness
projects within the RNHRD NHS Foundation Trust during the year to March
2007. A couple of examples are the audit of the care pathway for Complex
Regional Pain Syndrome, which showed that the average patient was staying
for sixteen days instead of 37 as previously (the results of this have been
presented locally and it is also planned to present them at a national
conference), and an audit looking at the time taken between a clinic and the
discharge of the clinic letter to the patient’s GP (copied to the patient, if
appropriate), which showed an average of between ten and eleven days; this
will be re-audited following a secretarial reorganisation.

If more information is required, that month’s full list of clinical audit projects at
all stages of development can be found after that section.

                    Annual Clinical Effectiveness and Audit Summary Report 2006/07: a selection of projects

                         Commenced      Completed    Outcomes                    Action plan
Mandatory Audits
Health Records –
Under 18s health         November       November     Scored 90% or above for    Raise awareness of need to sign
records review           2006           2006         half the criteria          and date any alterations in health
                                                                                records and ensure they contain
                                                                                no loose papers.
Adult Health Records     December       February     Main issue loose papers in To remind staff of the importance
                         2006           2007         folders.                   of filing all papers. Other
                                                                                recommendations to be agreed
Infection Control
Handwashing                             2006/07      88% compliance rating       Included in Infection control
compliance                                                                       2007/08 annual plan
Hydrotherapy                            October      100% compliance rating      Included in Infection control
                                        2006                                     2007/08 annual plan

Mattress audits                      2006/07     Completed annually,          Included in Infection control
                                                 mattresses replaced as       2007/08 annual plan
Ward Environment -                   2006/07     All scores 70% or over       Included in Infection control
10 areas in the Trust                                                         2007/08 annual plan
Hydroxychloroquine      January 2006 July 2006   Variable levels of recorded Stickers designed to facilitate
Monitoring                                       assessment                  better documentation, RCO
                                                                             guidelines in all clinic rooms
Antibiotics audit       March 2006   July 2006   Generally good practice of Medicines Management Plan for
                                                 the medical prescribing for 2006/07 included;
                                                 the use of antibiotics      Development of guidelines of
                                                 based on the guidelines     antibiotic use for the treatment of
                                                 There are more infections Clostridium Difficile.
                                                 on the Head Injury unit     by Medicine management group.
                                                 than Rheumatology unit,     Prophylaxis prescribing and
                                                 but nearly all head injured treatment to be re-audited.
                                                 patients are admitted from
                                                 previous hospitals and
                                                 have already been
                                                 exposed to healthcare
                                                 acquired infections.

NICE guidelines for     February                 Repeat of previous audit.    Medicines Management Plan for
epilepsy/phenytoin      2007                     Data being collected         2006/07 (following previous
management                                                                    audit) included;
                                                                              Medicines Management to
                                                                              produce a local protocol for

                                                                             Phenytoin cessation and local
                                                                             protocol for use of alternative
                                                                             anti-epileptic medication.
                                                                             Yearly audit of patients from
                                                                             admission to discharge on a
                                                                             continual basis to inform clinical/
                                                                             medical practice.
                                                                             Increase staff awareness through
                                                                             A care pathway for head injured
                                                                             patients diagnosed with epilepsy
                                                                             in long term conditions initiative.
Other mandatory
Copies of             December     February     90% of correspondence        New policy agreed by all. Reaudit
correspondence to     2006         2007         copied, but variations       Feb 08
patients                                        between clinicians
Vital aspects of      Completed monthly         Ongoing audits checking      Actions implemented following
clinical service                                compliance with nursing      monthly review of results by
                                                standards. Results           Ward Matron. To be extended to
                                                reported to Board in         include other professions.
                                                performance reports
Integrated care       November     February     All standards of care met.   Reaudit February 2008
pathway for complex   2006         2007         Mean length of stay down
regional pain                                   from 37 to 16 days
NICE guidelines for   November     Data         Developed into a care        Results completed. Report to be
etanercept and        2006         collection   pathway for patients with    presented
infliximab                         ongoing      rheumatoid arthritis.

Saving Lives              Completed monthly          Dept of Health initiative re healthcare-associated infections.
Patient access to         February       February    Only one case; access          Reaudit February 2008
health records            2007           2007        provided in 4 days

Local Audits
Compliance with           March 2006     June 2006   Some failings, but            Recommendations made. To be
ARMA standards re                                    ambiguity re                  reaudited
cardiovascular                                       responsibilities of primary
monitoring                                           care practitioners
Patient Reports –         October 2005               Data collection ongoing
evaluation of
satisfaction of health
care professions and
family members with
new patient reports.
Neuro Rehabilitation      May 2006                   Data collection ongoing       To continue with the audit until
UK FIM & FAM                                                                       sufficient data is available.
Outcome Measures.
Dietician input to care   October 2006 May 2007      Report showed need for        To repeat audit looking at
of discharged patients                               home enteral feeding          performance since appointment
                                                     dietician (now in post)

Length of time        February        February   Data from Oct 06. 74% of        Policy changed to allow more
patients wait in      2007            2007       last patients in clinics seen   supervision for junior doctors.
outpatient department                            within 30 minutes of            Reaudit Feb 2008
                                                 appointment time
Compliance with BSR     November      Ongoing    Data collected and              Report to be finalised and results
and other standards     2006                     analysed                        presented. To be reaudited
in monitoring RA                                                                 (possibly in combination with
patients                                                                         ARMA standards)
Time taken for clinic   August 2006   November   Mean was just over 10           Secretarial reorganisation.
letters                               2006       days between clinic and         Reaudit Nov 2007
                                                 dispatch of letter


Full list of all projects: March 2007

R = Rheumatology, N = Neuro rehab, PM = Pain management, CM = Clinical
measurement, T = Trustwide

Project                             Progress/action required    Timescale
NICE1/06 published Mar 02: RA –     See ICP2/06 below
etanercept and infliximab (R)
NICE2/06 pub June 03: Head          To be arranged
injury (M Burgess, N)
NICE3/06 pub Oct 04: Epilepsy (S    Audit completed Feb 06.
Rodgers, N)                         Small sample. 2 patients
                                    discharged on
                                    phenytoin, 1 given
                                    cessation advice. Data
                                    collection for reaudit
                                    started Jan 07. ICP to be
NICE4/06 pub June 03: Infection     See IC1-18/06
control (A Pacey, T)
NICE5/06 pub Feb 06: Nutrition      AH to develop audit of
support in adults (A Pacey, A       areas not covered by
Holdoway, T)                        Essence of Care MUST
NICE6/06 pub July 04: Self-harm     Policy being developed
(various, T)                        and agreed. To be
NICE7/06 pub Sep 05: Pressure       Woundcare ICP to be
ulcer management (L Michell, T)     agreed by Clin Gov then
                                    implemented: to be
                                    audited 6 months after
NICE8 and 9/06 pub Dec 04:          Essence of Care mental
Anxiety and depression (A Pacey,    health project
NICE10/06 pub July 06: Psoriatic   To be arranged
arthritis (E Korendowych, N
Waldron, R)
                       National Service Frameworks
NSF1/06: Children and younger      Audit criteria to be
people (H Connell, T)              agreed by Children’s
NSF2/06: Long-term conditions (M Data collection form to        Due Mar 07
Burgess, N)                        be agreed
NSF3/06: Older people (C           Data collection form to
Harland, T)                        be agreed

Project                               Progress/action required Timescale
                           Integrated care pathways
ICP1/06: Ankylosing spondylitis       Meeting 7 Mar
(M Stone, M Chan, R)
ICP2/06: Anti-TNF: see NICE1/06 Data collection
above (M Perry, D Smith, L
Michell, R)
ICP3/06: Complex regional pain        All standards of care
syndrome (C McCabe, R)                met, mean LOS down
                                      from 37 to 16 days.
                                      Report to be submitted
ICP4/06: Endoscopies (B Pickford Completed May 06.
N, C Washbrook, R)                    Report to be submitted
ICP5/06: Falls (J Russell, M          Pre-ICP data collection  Started Aug
Tipler)                                                        06
                                Infection control
IC1/06: Sharps bin audit (B           Completed annually:      Reaudit April
Pickford, T)                          2006 – 83%               07
IC2/06: Mattress audit: alternate     Completed annually       Reaudit April
pressure (B Pickford, A Pacey, T)                              07
IC3/06: Housekeeping audits (B        Completed: monthly November – Rheum
Pickford, A Pacey, T)                 74%, Neuro 64%
IC4/06: Handwashing compliance Completed annually              Reaudit April
(B Pickford, A Pacey, T)              ICNA - 88% for Trust.    07
                                      Road show (technique)
IC5/06: Clinical measurement (B       Completed annually       Reaudit June
Pickford, T)                          Ward env 72%             07
IC6/06: Endoscope re-processor        Completed 3-monthly      Reaudit Nov
external audit (B Pickford, R)                                 06
IC7/06: Mattress audit (A Pacey,      Completed annually –     Reaudit June
N)                                    HIU 7 new covers         07
IC8/06: OPD audit (B Pickford, R) Completed annually Nov Reaudit Dec
                                      06 66%                   07
IC9/06: Clinical waste (D Phillips,   Completed annually       Reaudit May
A Pacey, T)                           80% (Waste training      07
IC10/06: X-ray (B Pickford, A         Completed annually       Reaudit July
Hicks, CM)                            Ward Env :80%            07
IC11/06: OPD occupational             Completed annually       Reaudit Mar
therapy and physiotherapy (B          OT & PT Ward Env 81% 07
Pickford. C Washbrook, T)
IC12/06: Hydrotherapy (M Tipler,      Completed Oct 06.        Reaudit Oct
T)                                    100% success             07
IC13/06: Pain management (B           Completed annually –     Due April 07
Pickford, PM)                         not 2006 because of
                                      new premises
IC14/06: Neuro rehab (A Pacey,        Completed Nov 06 –       Reaudit Nov

Project                           Progress/action required   Timescale
N)                                HDU 66%, Therapy           07
                                  96%, CQ 74%, Camb
IC15/06: Glove compliance (B      Data analysis              Started Oct
Pickford, T)                                                 06
IC16/06: Mattresses: Trim St,     Completed annually –       Reaudit Dec
Neuro rehab, Rheum (B Pickford,   Trim St 2 new              06
R, N)                             mattresses, R 2
                                  mattresses and covers.
IC17/06: Rheumatology (B          Completed annually          Reaudit Jan
Pickford, R)                      Ward Env 70%                07
IC18/06: Diagnostic suite (B      Completed annually          Reaudit Feb
Pickford, C Washbrook, external                               07
auditors, R)
IC19/06: Continence (R               Completed monthly N, as required R
Tapfumaneyi N, L Hudson R)
                               Essence of Care
EC1: Communication (A Pacey, T)                               Due Oct 07
EC2: Continence, bladder and         Completed in Neuro       Started Jan
bowel care (A Pacey, T)              Rehab, awaiting Rheum 07
EC3: Personal and oral hygiene                                Due Sept 07
(A Pacey, T)
EC4: Food and nutrition (A Pacey,                             Due July 07
EC5: Pressure ulcers (A Pacey, T)                             Due Aug 07
EC6: Privacy and dignity (A                                   Due Apr 07
Pacey, T)
EC7: Record keeping (A Pacey,                                 Due Mar 07
EC8: Safety of clients with mental Completed in Neuro         Started Feb
health needs in acute and general Rehab, awaiting Rheum 07
hospital settings (A Pacey, T)       and PMU
EC9: Self care (A Pacey, T)                                   Due May 07
EC10: Health promotion (A Pacey,                              Due June 07
EC11: Managing difficult                                      Due Nov 07
behaviour (A Pacey, N)
EC12: Tracheostomy (A Pacey,                                  Due Dec 07
                               Other mandatory
M24/04: Quality of casenotes for     Completed Feb 2007.
CNST (H Sewell, N Frayling, T)       Main finding: 83% had
                                     loose papers (up from
                                     80% in Dec 04). To NF
                                     for recommendations

Project                              Progress/action required      Timescale
M25/04: Copies of                    Completed Feb 07. 82%
correspondence to patients (H        failure to record patients’
Sewell, T)                           preferences in
                                     casenotes (up from 50%
                                     in Dec 04). 90% of
                                     correspondence copied
                                     to patients (up from
                                     73%), but variations
                                     between individuals. To
                                     be discussed with
M1/06: Phlebotomy (N Burke, N)       Completed monthly.
M2/06: Quality of patient notes (L   To be completed               Mar 07
Covill, N)
M3/06: Quality of patient notes (M   Completed May 06. 74%         Reaudit May
Maeda, PM)                           overall, 0% entries           07
                                     timed, low scores for
                                     documentation of errors.
                                     Fed back to individuals
                                     and at team meetings
M4/06: Quality of patient notes (C   Report received for        Nov 06:
Washbrook, K Burge, R)               adolescents                adolescents
                                                                to be re-
                                                                audited Nov
M5/06: Manual handling (S            Completed Jan 07,          Started Nov
Ibbunson, T)                         awaiting report            06
M6/06: Vital aspects (A Pacey, C     Completed monthly, target 75% - Dec
Harland, N, R)                       73% (action plan sent to AP), Jan 78%
M7/06: Management of controlled      Data analysis              Nov 06
drugs (J Cooke N, C Harland R)
M8/06: Consent for research          Clinical lead to be           Reaudit due
patients (T)                         identified                    Nov 06
M9/06: Research governance (T)       Clinical lead to be           Reaudit due
                                     identified                    Nov 06
M10/06: Compliance with              Completed June 06 64 -        Reaudit June
antibiotics policy (A Pacey, T)      100%                          07
M12/06: Resuscitation policy (S      Form to be piloted            Started Oct
Ibbunson, T)                                                       06
M13/06: Diagnostic reference         Completed Mar 06:             Reaudit Mar
levels (A Hicks, CM)                 100% within                   07
                                     recommended levels
M14/06: Quality assurance            Completed April 06:           Reaudit Mar
programme (H Starritt [RUH], CM)     thorough records with         07
                                     good results. AEC tests
                                     increased to 4 p.a.
M15/06: Identification of            Completed Mar 06: 97%         Reaudit Mar
practitioners, operators and         on approved list. 2           07

Project                            Progress/action required   Timescale
referrers (S Hatton, CM)           exceptions due to staff
                                   starting and leaving
M16/06: Informed consent (M        To be reaudited            Reaudit Nov
Burgess, N)                                                   07
M17/06: Informed consent:          Completed Nov 2005.        Reaudit Nov
endoscopies (A Collins, R)         98% completed forms        06
M18/06: “Do Once And Share”        Operational
project (AK Clarke, C Fokke, R)
M19/06: “Saving Lives” (DoH) re    Completed monthly
healthcare associated infection:
high impact interventions (J
Cooke, N)
M20/06: “Saving Lives” (DoH) re    Completed monthly
healthcare associated infection:
high impact interventions (C
Harland, R)
M21/06: “Saving Lives” self-       Self-assessment
assessment and action planning     completed, actions
tool (A Pacey, T)                  planned and undertaken.
                                   Feb 07 - 4 green, 4
                                   amber, 1 red
M22/06: Endoscopies: Healthcare    Completed               Reaudit April
Commission (C Washbrook, B                                 07
Pickford, R)
M23/06: Discharge of patients      Care pathway to be
against discharge policies (MA     approved
Darlow, C Washbrook, N, R)
M24/06: Drug charts (P Coulter,    Completed Sep 06. Most
T)                                 common error in 3 areas
                                   was omission of
                                   signature by qualified
                                   nurse on chart.
                                   Continued surveillance
                                   Electronic charts
                                   expected in 2007
M25/06: NCEPOD: Cardiac            Form to be piloted
arrests (S Ibbunson,T)
M26/06: Timescale for patient      Completed Feb 07. 1        Reaudit Feb
access to health records (H        case in previous 12        08
Sewell, T)                         months: access in 4
A4/05: Information days for        Data analysed Dec 05,
relatives (L Russell, D Aronson,   awaiting report
A5/05: Training for managing       Awaiting report

Project                               Progress/action required     Timescale
difficult behaviour (L Russell, T
Mills, N)
A15/05: Completion of waiting list  Data collected and
forms (A Menon, R)                  analysed August 05.
                                    30% failure to complete.
                                    Awaiting clinical lead to
A16/05: Monitoring of               Completed and
hydroxychloroquine (M Chan, R)      presented. Variable
                                    levels of recorded
                                    assessments. Stickers
                                    designed to facilitate
                                    better documentation,
                                    RCO guidelines in all
                                    clinic rooms, lean body
                                    weight in place on Clinic
                                    PCs (to be mentioned at
                                    Med Staff meeting)
A23/05: Compliance with ARMA        Completed, presented
standards re cardiovascular         and accepted for
monitoring in RA patients (J        publication. Changes of
Pauling, R)                         practice to be
A1/06: Nursing policies, guidelines Ongoing review. System
and procedures (J Sirman, T)        being set up to ensure
                                    organised audits
A2/06: Advice line documentation Data collected, awaiting
(S Brown, L Michell, R)             analysis
A3/06: Efficacy of occupational     Data collection                Started Oct
therapy interventions for upper                                    04
limb problems (L Cory, R)
A4/06: Clinical reflection (C       Completed April 2006.
Vause, N)                           84% wanted it to
A5/06: Wessex rehab units audit     Data collection: MB to         Due Nov 06
of BSRM/RCP standards (M            check whether results
Burgess, N)                         still acceptable
A6/06: Recording FIM and FAM        Data collection                Started May
measures (H Clarke, N)                                             06
A7/06: Compliance with BSR and Data collection                     Started Nov
other standards for annual                                         06
monitoring in RA patients (M
Piper, R)
A8/06: Delays in outpatient         Completed Feb 07 with
appointments (C Washbrook, J        data from Oct 06. 29%
Down)                               of first patients in clinics
                                    seen on time. Last
                                    patients in clinics
                                    delayed by 25 mins

Project                               Progress/action required   Timescale
                                      mean (range 0-95), 74%
                                      of last patients seen
                                      within 30 mins. To be
                                      discussed with doctors
A9/06: Evaluation of Rosenbek         Completed, presented       Reaudit Mar
penetration-aspiration scale for      Sep 06. Low inter-rater    07
SLTs (H Castledine, SLT)              reliability so scale not
                                      yet introduced
A10/06: Use of methotrexate (E        Form to be piloted         Planning
Korendowych, M Piper, L Michell,                                 started July
C Washbrook, R)                                                  06
A11/06: Information given to          Form to be piloted         Planning
patients on methotrexate (E                                      started July
Korendowych, M Piper, L Michell,                                 06
C Washbrook, R)
A12/06: Appropriateness of            Awaiting report            Started Sep
referrals for MRI and ultrasound (L                              06
Coates, R)
A13/06: Timescale of MRI and CT       Data collection            Started Sep
reports from RUH (S Hatton, CM)                                  06
A14/06: Effectiveness of Vital        Data collection            Planning
Aspects audits (M6/06) (A Pacey,                                 started Sep
C Harland, J Cooke, T)                                           06
A15/06: Dietician input to care of    Awaiting report            Started Oct
discharged patients (A Beams, T)                                 06
A16/06: Time taken for clinic         Data analysis. Aug data:   Awaiting
letters (N Frayling, T)               16/180 within 5 days,      secretarial
                                      mean 11 days, range 1-     reorganisation
                                      48 days. Sep: 13/148
                                      within 5 days, mean 10
                                      days, range 1-61 days
A17/06: Silver alloy catheters (A     Continual monitoring       Started May
Pacey. T)                                                        06
A18/06: Consent for and               Data collection            Started Oct
confidentiality of e-mail                                        06
communications (K Vowles, PM)
A19/06: Transmission of MRSA (U       Data collection            Started Oct
Sukys, N)                                                        06
A20/06: Menu audit by SLTs (H         Completed Sep 06.          Reaudit due
Castledine, T)                        Grade B diet not used,     Mar 07
                                      Grade C variable
                                      consistency, Grades D &
                                      E need more choices
A21/06: Documentation of entry to     92% completed following Reaudit Oct
and exit from programmes (K           new procedure           07
Vowles, PM)                           introduced April 06.
                                      Patient on in-hospital
                                      programme not

Project                           Progress/action required   Timescale
                                  documented. Plan to
                                  correct this
A22/06: Objectives of use of      Planning                   Started Nov
walking aids (R Passingham, J                                06
Clarke, PM)
A23/06: Self-administration of    Data analysis              Started Oct
medication (C Harland, R)                                    06
A24/06: Medical devices policy    Data collection form to    Started Dec
and management procedure (D       be piloted                 06
Hartshorn, T)
A25/06 Oral care (J Renno, N)     Criteria to be agreed      Started Dec
A26/06 Major incident plan (C     To be audited annually     Document
Fokke, T)                                                    pub Sep 06
A27/06 Occupational therapists’   Form being piloted         Started Dec
continuing professional                                      06
development (S Derham, T)
A28/06 Time taken for discharge   Data collection            Started Jan
letters (C Washbrook, R)                                     07
A28/07 Physiotherapy DNAs (M      Data collection            Started Feb
Tipler, R)                                                   07