1. Clinical Audit for Board Assurance Anne H Lawson Director of Governance – HDFT Visiting Fellow – Loughborough University

2. NHSFT Code of Governance Directors are ultimately and collectively responsible for all aspects of the performance of the Trust How can they know?

3. The Balance Assurance or detailed knowledge Too much or too little Strategic or operational TRUST CHALLENGE

4. Role of Internal Audit Advising the Board of the adequacy and effectiveness of overall arrangements Provide a coordinating role on assurance issues Work closely with other reviewers

5. INTERNAL AUDIT Provides the Audit Committee with an “opinion on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes”

6. WHY FOCUS ON CLINICAL AUDIT? The Audit Committee should consider “…how best to engage with clinical audit to meet its own needs for assurance…” “..expect to see regular reports of the outcomes of Clinical Audit work” Audit Committee Handbook January 2010

7. SHOULD THE AUDIT COMMITTEE CONSIDER CLINICAL GOVERNANCE ISSUES? “consider clinical objectives and risks in the Assurance Framework” Audit Committee Handbook January 2010

8. Changes to the Audit committee focus Challenging for non-execs who may have no health background Challenging for trust clinical effectiveness and audit staff.

9. Why do we carry out Audit?

10. Local Audit

11. National audit

12. Assurance

13. Board of Directors Sub groups of Board

14. Outcomes of audits For assurance Measure performance against a known standard and facilitate improvement Benchmark performance against other organisations To teach the practice/art of auditing (junior doctors)

15. There is real gain to be realised from Internal audit and clinical audit working together although each will always have their particular remit.

16. Challenges We use different languages We have different purposes for doing an audit We report differently We need to recognise diversity We have different expected outcomes

17. Challenges Self assessment Clinical Outcomes Compliance Evidence base standards Independent view Systems and Controls

19. Levels of assurance Description of compliance Full Significant Limited None

20. Perceptions Board are nervous of limited assurance If worry area should expect gaps – make clear expectation at start Re-audit WILL be for assurance purposes Do not drive the issues underground

21. False Assurance We can only ‘measure’ what we can measure. If we have no limited assurances we have not prioritised the correct areas

22. Sources Of Assurance examples Internal Internal Audit Clinical Audit Assurance Framework Governance Annual report Robust reporting and accountability structures Performance Indicators Self assessments- research/information governance, child protection Complaints/incidents/claims External NHSLA National Audits Audit Commission Regulator – CQC/Monitor Audit Office College Visits Deanery Visits Cancer Peer Review Performance Indicators Benchmarking Patient and Staff surveys

23. Standards to enable comparisons CQC CQC reviews and reports Independent reviews Monitor NICE Guidelines etc. NHSLA Risk Management Standards Patient Safety Alerts Health Service Circulars Managers Code of Conduct Other DH Standards e.g. Internal Audit, IWL, etc. Other ‘arms length’ bodies e.g. National Patient Safety Agency, MHRA, NHS Estates, etc. National Confidential Enquiries Independent reviews Parliament - laws and regulations Royal Colleges Other professional organisations e.g. IHM Other UK health department related e.g. Scottish Inter-Collegiate Network (SIGN) Regulatory bodies e.g. HSE British & International Standards (BSI & ISO) Accreditation e.g. HQS, Trent, Laboratories, etc. Other independent healthcare organisations e.g. ECRI Investors in People (IIP) Trade associations Local policies etc. DH & related StandardsOther

24. Effectiveness and Outcomes CQUINS Mortality rates– now on Choose and Book CQC measurables Safety measurables Specialty audits National audits Nice Other recommendations Trust objectives

25. Assurance framework Used to let the Board know status of organisation Informs the annual governance statement Identifies gaps in assurance Is a dynamic document used to update the Board as to actions.

26. Assurance Framework Highest level for Board Assurance Identify resource for gaps Revisit it at Board after 6 months Action Plan for leads Should drive the working of the Board Cross Check against progress Evidence for Audit, CQC and Commissioners

27. Consultation Int audit set programme Directors Directorates Clinicians Regulation Worry areas Local interest

28. Planning the audit programme Must dos for external and internal audit – systems and processes – for assurance Assurance framework and risk registers Gap analyses from national audits etc – audit to determine progress Quality improvement work streams Regulators – CQC, Monitor NHSLA/CNST Worry areas where we do not exactly know the problem Local – very clinical audit – for learning

29. Structuring the programme Pure Internal audit Joint Audits Pure clinical audits – Trust wide – Local

30. Prioritisation of audit Not – When you know exactly what is wrong – To gain investment – To highlight an area

31. Joint audits Different starting points Different language Assurance versus other Measures of success different Challenges for reporting and scoring Set the brief very carefully

32. Structure in HDFT

33. Board of Directors Audit Committee Standards Group Clinical Effectiveness and Audit Group Quality and Governance Group

34. Director team Standards Group Corporate Risk Review Group Clinical Effectiveness and Audit Group Chief Executive Complaints and Risk Management (CORM)

35. Clinical Effectiveness and Audit Group Input from Specialty Leads for clinical team and to support junior doctors Prioritisation of audit support Data-base of Audits Teaching of Audit methods Ensuring Change Sharing Good practice

36. Standards group Minutes from CEAG Clinical Audit report Gap analyses from National audits and national recommendations/HLEs/ Confidential Enquiries Action Plan monitoring including CAS alerts and SUIs External visits and accreditations National data submissions Prioritisation of audit support to standards audits Audit Plan with CEAG

37. Audit Committee Minutes for standards Internal audits and action plans Standards report Clinical audit report Joint Audit plan – who and when Corporate Risk register Assurance framework and updates