risk assessing clinical audit findings anne jones, head of clinical audit and effectiveness kingston...
TRANSCRIPT
Risk assessing
clinical audit findings
Anne Jones, Head of Clinical Audit and EffectivenessKingston Hospital NHS Foundation Trust
Session objectives
To share our process for introducing a risk assessment approach to clinical audit results, focusing on:
•Why take a risk assessment approach?
•The road to risk assessment
•Undertaking the risk assessment – an example
•Escalation process
•Training the risk assessors
•Benefits to patient care
•Practical example
At a trust-wide or corporate level
Clinical governance describes the structures, processes and culture needed to
ensure quality of the care and continuous improvement
www.gov.uk/government
Quality governance used byMonitor to refer to how a Board should lead on quality and identify and manage risks to
quality.1
Why take a risk assessment approach?
1 Bullivant J, Burgess R. Corbett-Nolan A. and Godfrey K. (2012) Good Governance Handbook. HQIP/Good Governance Institute
At the front line
To support frontline clinicians to assess the significance of
clinical audit results and ensure improvement in patient care
Why take a risk assessment approach?
Relationship between clinical audit and risk
Risk driving clinical audit -High risk is one of the main drivers of clinical audit topic choice 2
-‘Address specific local risks’ 3
-At Kingston, risk registers reviewed for topics for annual clinical audit programme and risks arising throughout the year are added to the clinical audit programme
2 Burgess R. (2011) New Principles of Best Practice in Clinical Audit , HQIP 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP
To: Anne Jones
Relationship between clinical audit and risk
Clinical audit driving risk management ?-Quantify the implications for clinical and organisational practice including potential for harm
Clinical audit can …. Identify major risk, resource and service development implications in an NHS trust ‘3
-At Kingston, process for linking clinical audit to risk and risk registers had not been formally established
3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP
Other drivers
HQIP’s Clinical audit: A simple guide for
NHS Boards and partners3
“Ensure that clinical audit results having potential significance, due to the identification of a risk, are brought to the attention of the clinical governance committee …..”
Grant Thornton’s paper ‘Clinical audit: a brave new world’? (2011)4
“Results are not fed into organisational risk assessment. We see many examples of where individuals or groups learn from clinical audit and adjust their practice accordingly. However, we see virtually no examples where the results of clinical audit feed back into the board’s risk assessment and business planning.
3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP4 Dossett P. (2011) Clinical audit: a brave new world? Grant Thornton
Francis Report5 - Recommendation 5: The Board should review audit processes and outcomes on a regular basis.
Keogh Report 20136: Ambition 2The boards and leadership of provider and commissioning organisations will …have rapid access to accurate, insightful and easy to use data about quality at service line level. A failing of one of the hospitals was noted as “The governance systems are not providing the expected level of assurance to the Board, and the escalation to the Board of risks and clinical issues is inconsistent”
Berwick Report 20137
The most valuable information of all is information on risks and on things that have gone wrong p10
5 Francis Report http://www.midstaffspublicinquiry.com/report6The Keogh Report (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England7The Berwick report (2013) Improving the Safety of Patients in England
How does this fit with the current national picture?
What were we hoping to achieve?
To provide clinicians, managers and clinical audit staff with a system to categorise and quantify the level of concern/risk
o Escalate appropriate concerns upwards
o Target resources
To ensure a systematic approach where results are below standard
To drive robust action planning and quality improvement
To focus on areas where quality improvement is most required
To feed back into Board’s risk assessment and business planning
System Timeframe Detail
General reporting against standards
Prior to 2011
Clinicians set standard to achieve prior to audit – met/not met
RAG rating of clinical audit results
2011 Clinicians set RAG standards to achieve prior to audit starting, producing RAG audit results.
ReviewClinicians found it difficult to set amber and red objectively.
Unclear whether always flagging up the major issues or right issues.
Risk assessment of clinical audit results
2013 Clinicians set ‘green’ standard to achieve. If not achieved, risk assessment undertaken to more objectively categorise amber/red.
Kingston Hospital’s road to risk assessment
5 steps in risk assessment
http://www.hse.gov.uk/risk/fivesteps.htm
Kingston’s risk assessment form 8
8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure
Grading the consequences for audit of clinical quality
1 Negligible
2 Minor
3 Moderate
4 Major
5 Catastrophic
Peripheral element of treatment/care suboptimal
Overall treatment/care suboptimal
Treatment/care of reduced effectiveness
Unacceptable quality of treatment/care
Totally unacceptable quality of treatment / care
Minimal intervention / treatment
Minor intervention / treatment
Moderate injury requiring intervention
Major injury leading to long term incapacity
Incident leading to death
Increase in length of stay by 1-3 days
Increase in length of stay by 4-15 days
Increase in length of stay by >15 days
Likelihood scoring1
Rare2
Unlikely3
Possible4
Likely5
Almost certain
Probably never happen
Not expected to happen but may
Might happen occasionally
Will probably happen but not persistent
Will undoubtedly happen, possibly frequently
8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure
At start of each clinical audit project, a target for acceptable care or treatment is agreed by the clinical team – ‘green’ RAG rating. Linked to policy, guideline or set standards.
The audit is carried out and the results compared to the target(s) set.
Result > target = Green
Result < target risk assessment to categorise level of risk
Risk Rating < 8 = Amber rated Audit
Risk Rating > 8 = Red rated Audit
The process
Hazards (potential to cause harm):
Antibiotic acquired infection, eg C. difficile, increased resistance to anti-biotics, side effects from treatment, longer recovery period, increased cost
EXAMPLE: Antibiotic prescribing
Audit criteria: Target Result
Indication given
95%
96%
Stop/review date recorded 70%
Duration in accordance with guideline 79%
Antibiotic prescribed according to guideline or Micro 89%
Review/stop dates not put on antibiotic prescription charts and patients left on antibiotics too long. Incorrect antibiotics prescribed.
Risks (effect on the patient/hospital):
Risk ratingConsequence 3 (moderate) x Likelihood 3 (possible) = 9 (RAG rated ‘Red’)
Hazard: Incorrect ABDuration of AB too longRisks: AB acquired infection; Treatment side effects; Longer recovery; AB resistance; Cost
Medicines policyM-F Pharmacist WRMicro/Pharmacist twice weekly WRStop date section on drug chart
Trust-wide
Safe and effective prescribing of antibiotics
Training for junior docsConsultant supervision on ward roundsWeekly publication of dataDaily Micro/Pharm WRs
3 3 9 2 3 6
Clinical Audit report
Summary of results and RAG ratingAudit criterion Result Standard set % Risk rating C x L RAG rating
Indication for AB given 96%
95%Stop date on chart 70%
3 x 3 = 9 RedCorrect duration 79%
Correct antibiotic 89%
Action PlanRecommendation Action Barriers Responsibility Timescale
Train junior doctors Add to induction programme None F1/F2 tutor 30.8.13
Ensure drug charts are fully completed
Supervision on ward rounds None Consultants Weekly
Ensure staff know results
Publication via KPI scorecard None Audit Facilitator 1st of each month
Extend input from Micro/Pharmacy
Increase Antibiotic Pharmacist to FTE
Budget restrictions
Pharmacy Manager
30.9.13
Escalation of ‘red’ audit results
* Sub Committee of the Trust Board
Risk Register
Red
◄ Challenge ►
An iterative process ….
Original Revised
Risk assessment for all criteria that did not meet standard
Risk assessment of findings as a whole
Undertaking a ‘quick’ risk assessment and proceeding to full risk assessment if risk >8
The full risk assessment was not lengthy and this two-step process made it more complicated
Training
• Trust-specific training delivered to Clinical Audit Facilitators by Risk Manager
• Training delivered to our Clinical Audit Leads by Risk Manager and Head of Clinical Audit
• Audit project leads trained by Clinical Audit Facilitators at the time of undertaking a risk assessment
• All managers and senior nursing staff trained in risk assessments
Your turn ……..
Identify the hazards
List all the risks
Existing controls:Falls PolicyAuditsStaff trainingAnalysis of individual falls
Nursing / Trustwide
Describe the topic area
Falls Audit example
? ? ? ? ? ?
Hazard: Failure to provide care plans for all patients at risk of fallsRisks: Physical harm from fall; increase in LOS, increase in falls per1000 bed days
Existing controls:Falls PolicyAuditsStaff trainingAnalysis of individual falls
Nursing / Trustwide
Falls care plans
Falls Audit example
3 4 12 2 4 8
Conclusions
Greater clarity regarding the level of risk to patient care where clinical audit results do not meet standards – good for patients, clinicians and the Trust Board
Greater objectivity than previous system
Provides ‘at a glance’ results and allows clinicians, senior staff and Board members to concentrate on the things that matter
Change and quality improvement to patient care is enhanced by ensuring action plans are robust and staff are held to account for completion, via risk register
Work in progress• Building into overall business planning
Thank you for attending this workshop
Any questions