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Local Improvement Following National Clinical Audit Manchester 20 th September 2012

Local Improvement Following National Clinical Audit Manchester 20 th September 2012. Welcome. Housekeeping Why are we here? HQIP is committed to increasing the impact of national clinical audit (NCA)

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Local Improvement Following National Clinical Audit Manchester 20 th September 2012

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  1. Local Improvement Following National Clinical Audit Manchester 20th September 2012

  2. Welcome • Housekeeping • Why are we here? • HQIP is committed to increasing the impact of national clinical audit (NCA) • How can you ensure that your participation in NCAs leads to improvements in the quality of local services? • Sharing ideas and good practice

  3. Programme 10:00 Introduction – HQIP and the national perspective 10:30 Laying the Groundwork – policy and processes 11:00 Preparing for change – local example and group discussion 11:30 Refreshments 11:45 Breaking down the report – presentation and discussion 12:30 Lunch 13:15 Facilitating improvement 1 – effective action planning 14:15 Facilitating improvement 2 – change management 15:00 Refreshments 15:15 Case study – improvement in a local trust 15:45 HQIP NCA feedback mechanism – how can it help? 16:00 Workshop evaluation 16:10 Close

  4. HQIP’s role • 2008 – To manage and improve the national Clinical Audit and Patient Outcomes Programme (NCAPOP). • The Department of Health decides which projects should be part of NCAPOP, on the recommendations of the National Advisory Group on Clinical Audit and Enquiries (NAGCAE). • HQIP implements the decisions, commissions the projects, and manages the contracts with the NCA providers. • The programme is expanding – 31 active projects, 9 more planned • 2013 - Decision making will move to the National Commissioning Board, management contract will be renewed.

  5. HQIP’s role • HQIP also contract manages the National Joint Registry and the Clinical Outcomes Review Programme (CORP – previously National Confidential Enquiries) • What about non-NCAPOP NCAs? • HQIP has no direct control over projects outside the NCAPOP, but can advise and provide guidance • Wide variation in approach, methods and effectiveness • At present, no system of review or accreditation • Principles of Quality in National Clinical AuditHQIP 2012 http://hqip.org.uk/hqip-principles-of-quality-in-national-clinical-audit/

  6. Why participate? • Quality in the new health system (Draft report) National Quality Board 2012 https://www.wp.dh.gov.uk/publications/files/2012/08/nqb-quality-draft.pdf • Measuring quality and using clinical audit data to drive improvement • Statutory and mandatory requirements for clinical audit http://hqip.org.uk/statutory-and-mandatory-requirements/ • NHS standard contract • Providers must participate in the NCAPOP audits which are relevant to the services they provide • and must implement all relevant recommendations of any appropriate clinical audit.

  7. Why participate? • CQC Essential Standards • Outcome 16 - Healthcare providers must regularly assess and monitor the quality of the services provided. • They must use the findings from clinical and other audits, including those undertaken at a national level, and national service reviews to ensure that action is taken to protect people who use services from risks associated with unsafe care, treatment and support • CQC Quality and Risk Profiles • Used to monitor compliance with Essential Standards • Compiled from sources including NCA reports

  8. Why participate? • Monitor • Current compliance framework: Foundation Trust Boards must certify that they have effective arrangements in place for the purpose of monitoring and continually improving the quality of healthcare provided to patients. • Consultation on the new provider licence (2013 onwards) • NHSLA • Risk management standard 2.1: All organisations must have an approved documented process for making sure that all clinical audits are undertaken, completed and reported on in a systematic manner.

  9. Quality Accounts • Statutory obligation introduced by the Health Act 2009. • Act and regulations specify the format which must be used for clinical audit information. • Key content: • Number of national clinical audits and national confidential enquiries which the provider has participated in • Number of national and local clinical audit reports reviewed by trust board • Actions the provider intends to take to improve services • Clarity of reporting in the first year was ‘variable’, so Department of Health published the Quality Accounts Toolkit.

  10. Quality Accounts • The toolkit introduced the Quality Accounts list • The list is compiled by NAGCAE, publicised by HQIP http://www.hqip.org.uk/national-clinical-audits-for-inclusion-in-quality-accounts/ • The list includes both NCAPOP and non-NCAPOP audits, and the HQIP resource provides information on data collection schedules and reporting. • No obligation to participate in listed projects – BUT ‘For each national audit or confidential enquiry that you are not currently participating in, you are encouraged to explain your reasons for not doing so’ • Changes for 2013/2014?

  11. Summary • NCAs can lead to sustained improvements in local services • Trusts have contractual and statutory obligations to participate in NCAs, AND to report on what actions they take as a consequence • Patients, the public, commissioners, regulators and licensing authorities are all making increasing use of NCA results to make decisions about local services • How can you ensure that your participation in NCAs leads to improvements in the quality of local services?

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