Operational action plan Objective Action Lead Expected Timescale outcome To maintain an audit An audit Specialty audit leads (SALs) to programme and programme with produce /maintain a prioritised forward forward plan that clear time frames annual specialty clinical audit Annually reflects (proposed start and SALs programme including re-audits (20%) Jan Feb. – organisational need finish times) and a to ensure implemented actions have based upon the lead/ sponsor for improved patient care. national clinical audit each audit programme, Annual forward clinical audit An approved and Annually ensuring the timely programme approved by the validated forward SALs Feb - reporting of appropriate CSC governance clinical audit March outcomes and a committee/leads programme, local clinical audit Trust wide annual forward clinical An approved and Annually programme based audit programme is approved by the CESG validated forward March - on current best CESG chair clinical audit April evidence and good programme practice guidelines, SALs to ensure full participation in Full participation in including concerns/ National Audits as approved by the National Audit trends from Department of Health (DH) and the programme complaints, adverse National Clinical and Patient signed or serious incidents. Outcomes Programme (NCAPOP) as off by the Medical SALs Annually sponsored by the Healthcare Quality Director/ CESG Improvement Partnership (HQIP) and chair). required for the Trust Quality Account. Trust Quality Account compliance. SALs or appointed leads to produce Specialty portfolio SALs/ clinical outcome data to benchmark of clinical outcome appointed their service against national and local achievements for Quarterly lead/ peer groups CESG and Trust CESG Board
Operational action plan Objective Action Lead Expected outcome Timescale To maintain an audit programme and forward plan that reflects organisational need based upon the national clinical audit programme, ensuring the timely reporting of outcomes and a local clinical audit programme based on current best evidence and good practice guidelines, including concerns/ trends from complaints, adverse or serious incidents. Specialty audit leads (SALs) to produce /maintain a prioritised forward annual specialty clinical audit programme including re-audits (20%) to ensure implemented actions have improved patient care. SALs An audit programme with clear time frames (proposed start and finish times) and a lead/ sponsor for each audit Annually Jan – Feb. Annual forward clinical audit programme approved by the appropriate CSC governance committee/leads SALs An approved and validated forward clinical audit programme, Annually Feb - March Trust wide annual forward clinical audit programme is approved by the CESG CESG chair An approved and validated forward clinical audit programme Annually March - April SALs to ensure full participation in National Audits as approved by the Department of Health (DH) and the National Clinical and Patient Outcomes Programme (NCAPOP) as sponsored by the Healthcare Quality Improvement Partnership (HQIP) and required for the Trust Quality Account. SALs Full participation in National Audit programme signed off by the Medical Director/ CESG chair). Trust Quality Account compliance. Annually SALs or appointed leads to produce clinical outcome data to benchmark their service against national and local peer groups SALs/ appointed lead/ CESG Specialty portfolio of clinical outcome achievements for CESG and Trust Board Quarterly
Clinical%20Audit%20Strategy.docx