CHHS17/303

Canberra Hospital and Health Services Operational Policy Clinical Audit Policy

Policy Statement

ACT Health will maintain a robust and transparent clinical audit program across Canberra Hospital and Health Services (CHHS) to monitor the safety and clinical effectiveness of health services and the experience of patients who access these services. Clinical audit data will be used to inform and identify areas for improvement in the provision of safe, quality and person centred care.

Purpose

The purpose of this policy is to outline the intent, direction, and guiding principles of the clinical audit program.

Clinical audit is a key mechanism to monitor the delivery of high quality, patient-centred care. The focus of the clinical audit program is on learning and improvement. Clinical audits should be conducted transparently, with clear communication, and with a focus on positive outcomes. It is not intended that clinical audits be used for punitive purposes, nor as a substitute for ongoing quality control activities or in place of clinician/staff performance management frameworks.

Clinical audits and the resulting data collected as an output from the audit process will primarily be used to: inform Quality Planning, Quality Assurance, Quality Improvement inform and improve the provision of safe, quality services and person centred care; evaluate and monitor the organisation’s performance in relation to the National Safety

and Quality Health Services (NSQHS) Standards, including the collection of evidence for reporting purposes;

evaluate and monitor compliance with relevant legislation, standards and ACT Health policies and procedures;

identify and quantify clinical risks and the development of risk minimisation strategies; identify waste and other inefficiencies in processes and practices

The collection, use, storage and release of data collected from clinical audit activities must be treated sensitively and in line with the requirements set out in relevant legislation, ACT Public Service Code of Conduct and ACT Health policies and procedures listed at the end of this document. Clinical audit data may contain patient identifiable information in some instances and must be managed in line with relevant legislation, ACT Public Service Code of Conduct and ACT Health Policies and Procedures listed at the end of this document.

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Scope

This policy applies to all ACT Health staff involved in clinical audits, including the development, conduct and reporting on clinical audits, as well as the management of clinical audit data and results.

Roles & Responsibilities

CliniciansClinicians are required to: participate in clinical audits as directed by their managers when relevant to their service

area; immediately address any safety issues identified during a clinical audit; and implement and/or respond to relevant recommendations or improvements identified

through a clinical audit.

DivisionsDivisions are required to: review and monitor results of clinical audit and identify areas for improvement drive quality improvements to address identified issues communicate audit results and planned corrective actions at relevant forums (e.g.

quality and safety meetings) as appropriate

Clinical Effectiveness Team, Clinical Safety and Quality Unit, Quality Governance and Risk DivisionThe Clinical Effectiveness team is responsible for the clinical audit programs and is required to: provide appropriate governance, education, support and coordination of clinical audits

across CHHS; ensure processes are clear, transparent and effectively communicated; assist in the undertaking of clinical audits as directed or required; ensure the collection, use, storage and release of clinical audit data is managed in line

with relevant legislation, ACT Public Service Code of Conduct and ACT Health policies and procedures listed at the end of this document

liaise with clinical areas to ensure audit tools are fit for purpose; provide accurate and timely reporting of audit data and assistance with the analysis

and/or interpretation of results; monitor appropriate use of data for Quality Planning, Quality Assurance, and Quality

Improvement or improvements to patient care; and promote responsible and effective use of audit data including information sharing where

appropriate.

National Standards Governance Committees

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The National Standards Governance Committees provide direction on what needs to be monitored and/or audited in relation to meeting ACT Health’s obligations for compliance with the NSQHS Standards, and are responsible for: advising the Clinical Effectiveness Team of changes, reviews and updates to audit tools; monitoring, analysing and/or interpreting clinical audit results at a CHHS level; incorporating clinical audit results in the decision-making process for recommendations

for improvement at a system / CHHS level; and ensuring the application of evidence-based practice and monitoring to inform policy

development and review.

Related Policies, Procedures, Guidelines and Legislation

Policies Clinical Record Form Design and Approval Policy. Clinical Records Digitisation Plan Clinical Records Management Policy Clinical Records- Records Management Manual

Procedures Clinical Audit Procedure Clinical Record Documentation SOP Clinical Records - Release or Sharing of Clinical Records or Personal Health Information

SOP

Guidelines ACT Public Service Code of Conduct

Standards Standards of Practice for ACT Health Allied Health Professionals

Legislation Health Records (Privacy and Access) Act 1997 (ACT) Information Privacy Act 2014 (ACT) Human Rights Act 2004 Freedom of Information Act 2016

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Definition of Terms

Audit - A systematic review of clinical care against a pre-determined set of criteria 1

Data – Information collected for reference, measurement and/or analysis.

Monitoring – observations recorded either by clinical audit or other means of periodic, systematic review to assess the quality or safety of an aspect of care over a period of time.

Quality Assurance – activities to assess compliance with systems and processes that result in safe and reliable care.

Quality Improvement - The combined and unceasing efforts of everyone — clinicians, consumers and their families, researchers, payers, planners and educators — to make the changes that will lead to better consumer outcomes (health), better system performance (care) and better professional development. 2

Quality Planning - preparing, adapting, innovating, supporting safe and reliable decision making.

References

1. Australian Commission on Safety and Quality in Health Care. Hospital Accreditation Workbook. Sydney. ACSQHC. 2012.

2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Guide to the National Safety and Quality Health Service Standards for community health services. Sydney. ACSQHC. 2015.

Search Terms

Audit, Clinical Audit, Quality, Quality Assurance, Quality Improvement, Quality Planning, Monitoring, Data

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 19/12/2017 New Document Josephine Smith,

Director, CSQUCHHS Policy Committee

This document supersedes the following: Document Number Document Name

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register