Specialty clinical annual report to Specialty clinical be produced audit annual report containing evidence Annually of implemented SALs Jan - Feb improvements, learning, benefits to patient care Trust wide annual clinical audit report Annual report of Annually to be produced audit activity CAD outcome against May - the forward annual June audit plan. To improve the requirement for Improved evidence planned audit projects to be registered of audit activity and and improve the number of completed SALs Monthly evidence of projects submitted to the clinical audit outcomes/ results department. To ensure NICE SALs to ensure a prioritised forward Programme of audit guidance in all its rolling programme of audit topics SALs prioritised against Annually forms is prioritised which address NICE guidance in all its NICE guidance and used to produce forms. audit topics for the SALs and CSC governance leads to CAD/ clinical audit be made aware of the appropriate SALs Programme of audit programme to guidance impacting on their areas. /CSC prioritised against Monthly ensure evidence of NICE guidance clinical effectiveness and implementation/ leads compliance with best NICE guidance spreadsheets to be Evidence of trust practice guidance. updated regularly as new guidance is compliance against CAD Monthly published each month each published NICE guidance Status report to be presented to Summary of trust CESG compliance against CAD Quarterly each published NICE guidance. Ensure audit ID no.s are linked to Evidence of audit NICE guidance spreadsheets CAD activity against Monthly NICE guidance Ensure partial/non compliant guidance CAD/ is escalated to Risk Registers SALs /CSC Monitoring and Monthly controls in place leads To ensure Ensure compliance with the Clinical CAD/ Policy in date Annually organisational Audit Policy SALs compliance with Ensure compliance with the NICE CAD/ Policy in date Annually requirements policy SALs identified within the Ensure compliance with the NCEs CAD Policy in date Annually national quality policy agenda i.e CQC, CAD CQC compliance Annually CORPs, NICE.
Specialty clinical annual report to be produced SALs Specialty clinical audit annual report containing evidence of implemented improvements, learning, benefits to patient care Annually Jan - Feb Trust wide annual clinical audit report to be produced CAD Annual report of audit activity outcome against the forward annual audit plan. Annually May - June To improve the requirement for planned audit projects to be registered and improve the number of completed projects submitted to the clinical audit department. SALs Improved evidence of audit activity and evidence of outcomes/ results Monthly To ensure NICE guidance in all its forms is prioritised and used to produce audit topics for the clinical audit programme to ensure evidence of clinical effectiveness and implementation/ compliance with best practice guidance. SALs to ensure a prioritised forward rolling programme of audit topics which address NICE guidance in all its forms. SALs Programme of audit prioritised against NICE guidance Annually SALs and CSC governance leads to be made aware of the appropriate guidance impacting on their areas. CAD/ SALs /CSC leads Programme of audit prioritised against NICE guidance Monthly NICE guidance spreadsheets to be updated regularly as new guidance is published each month CAD Evidence of trust compliance against each published NICE guidance Monthly Status report to be presented to CESG CAD Summary of trust compliance against each published NICE guidance. Quarterly Ensure audit ID no.s are linked to NICE guidance spreadsheets CAD Evidence of audit activity against NICE guidance Monthly Ensure partial/non compliant guidance is escalated to Risk Registers CAD/ SALs /CSC leads Monitoring and controls in place Monthly To ensure organisational compliance with requirements identified within the national quality agenda i.e CQC, CORPs, NICE. Ensure compliance with the Clinical Audit Policy CAD/ SALs Policy in date Annually Ensure compliance with the NICE policy CAD/ SALs Policy in date Annually Ensure compliance with the NCEs policy CAD Policy in date Annually CAD CQC compliance Annually
Clinical%20Audit%20Strategy.docx