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

2. What is Audit?

3. “You’ve got to do it”

5. Key messages:
Service improvement
Team working

9. 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

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

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

12. CQC Improvement Action Plan
August 2015

13. “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)

14. 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)

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

16. 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”

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