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.

Why do we carry out Audit?

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

Assurance

regulation

CQC

NHSLA

HSE

CPA

HTAMonitor

Others

Internal Audit

External Audit

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

Challenges

Levels of assurance

• Description of compliance

• Full• Significant• Limited• None

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

Structure in HDFT

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