Meeting national standards for clinical audit

1. Meeting national standards for clinical audit NHS Litigation Authority Level 3 NHS Trust

2. Shared learning objectives • Policy on procedural documents • Audit plan • Clinical effectiveness strategy • Clinical effectiveness roles • Evidence • Surprises • Internal audit • On the day

3. Audit plans • Board level engagement: Audit & assurance committee; Trust board • Links with policy, strategy and is reflected in annual publication of audit plan guidance • Mid-year and end year review to check we were on track across the organisation • Audit report template adapted to form a standardised template for policy monitoring • Hospital transfusion committee • Resuscitation committee

4. Education Agenda Informs Clinical Effectiveness Activity Higher quality care National Guidance Confidential enquiries Improved outcomes Informed by Risk R & D Clinical effectiveness strategy Clinical audit policy: clear processes; Governance team / policy monitoring Lessons learnt from NCE and Audit Care improved by Pathways and Guidelines Risks reduced, changes in process

5. Clinical effectiveness roles

6. Internal audit • Action plan from each audit • Audit completion • Audit proposal form completion • Rationale behind clinical audits • Review of audit results and dissemination of audit results

7. Evidence • Audit reports • Other records (minutes / agendas etc) • Emails • Newsletters (actions) • Intranet • Familiarity with policy monitoring requirements

8. Wash-up Celebrate