Audit as a Tool for Motivation Dr Stefan Maz Associate Specialist in Anaesthesia and SAS Tutor Rotherham NHS Foundation Trust

What is Audit?

“You’ve got to do it”

Key messages: Service improvement Team working

Team? Chief Nurse Head of Clinical Governance Chief Executive Medical Director Head of Clinical Professions Associate Medical Director for Standards of Medical Care Named Nurse for Adult Safeguarding Assistant Director of Patient Safety & Risk Director of Corporate Affairs/Company Secretary

July 2015 15 “Must Do” actions 35 “Should Do” actions

“Audit Action Group” 9 – 12 SAS doctors Multi-specialty

CQC Improvement Action Plan August 2015

“Must-Do” Audits “Medical Records” – security, confidentiality and storage “DNACPR Documentation” – compliance with local and regional guidelines, completeness “Mental Capacity Act” – awareness, knowledge and understanding (medical staff, nurses, physiotherapists, occupational therapists, radiologists)

Finished on time! Reports delivered to: Quality Assurance Committee Strategic Safeguarding Group Corporate Informatics Committee Operational Quality, Safety and Experience Group (OQSEG) DNACPR Audit presented to: Department of Anaesthetics Clinical Effectiveness Meeting Medical Grand Round (joint presentation with Trust’s Head of Legal Dept)

What next? Medical Records Re-Audit – April/May 2016 ?Capacity and DNACPR ? Pharmacy/Medication ?Thrombo-embolic disease

With thanks to: Mike Stedman – Res Consortium Tracey McErlain-Burns – Chief Nurse Catherine Finnegan – Clinical Audit Specialist Philippa Collins – Head of Research “Audit Action Team”

Thank you for listening! Any questions? Dr Stefan Maz Associate Specialist in Anaesthesia and SAS Tutor Rotherham NHS Foundation Trust