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1、FBA Clinical Governance and Nursing Audit WorkshopClinical Governance Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services and safeguarding high standards of care and services. Clinical gove
2、rnance applies to all treatments and services. The three most recognisable components of clinical governance and those which involve you in quality improvement are; Clinical effectiveness activities including audit and redesign Risk management including patient safety Patient focus and public involv
3、ement These three components are delivered effectively when NHS Boards support staff to be skilled, competent and aware of quality improvement in the organisation by: Having clear, robust national and local systems and structures that help identify, implement and report on quality improvement Involv
4、ing health care staff, patients and the public Establishing a supportive, inclusive learning culture An awareness of local and national influences can help you understand how to use clinical governance systems and structures to make improvement happen in your area.Clinical effectiveness is the exten
5、t to which specific clinical interventions do what they are intended to do, i.e maintain and improve the health of patients securing the greatest possible health gain from the available resources.It is described as the right person (you) doing: the right thing (evidence based practice) in the right
6、way (skills and competence) at the right time (providing treatment/services when the patient needs them) in the right place (location of treatment/services) with the right result (clinical effectiveness/maximising health gain). Clinical effectiveness is thinking critically about what you do, questio
7、ning whether it is having the desired result and making a change to practice. It is based on evidence of what is effective in order to improve patient care and experience. This can happen at NHS Board, directorate, department or team, or individual level.Clinical effectives emerged in the late 1980s
8、 when the health service first introduced quality improvement methods as a result of the need to account for its management and clinical efficiency, effectiveness and value for money. In response to demands to provide evidence that medical treatments and services were effective, health professionals
9、 developed measures to report on and assess the quality of clinical services. These activities began to be known under the heading of clinical effectiveness and included: evidence-based practice clinical or medical audit to critically review current practice development of guidelines identification
10、of outcome measures HistoryClinical audit evolved from medical audit in the late 1980s as part of the process of implementing evidence-based practice in healthcare. In Scotland, the Clinical Resource and Audit Group (CRAG) was established in 1989 with a remit to lead the promotion of clinical effect
11、iveness. In particular, CRAG provided support for local and national clinical audit projects. The main areas of work taken forward by CRAG were: clinical effectiveness clinical audit outcome indicators clinical guidelines clinical governance. In 1993, in response to the promotion of evidence-based m
12、edicine and the work of CRAG, the Scottish Intercollegiate Guidelines Network (SIGN) was established. SIGN has responsibility for coordinating and overseeing national guideline development and includes representatives of all the medical specialties, nursing, pharmacy, dentistry, professions allied t
13、o medicine, patients, health service managers, social services, and researchers.Clinical audit was seen as key tool in the engagement and involvement of health professionals in the quality improvement and clinical effectiveness processes. Audit became a tool for checking evidence-based practice. Our
14、 National Health (2000), Partnership for Care (2003) and Delivering for Health (2005) have all emphasised the need to improve the quality of patient care and acknowledge that this is dependent on the enthusiasm and commitment of those working with patients. Clinical governance concepts and clinical
15、effectiveness processes have provided routes to sustain, measure and assess the impact of quality improvement in health care. The promotion and routine use of evidence-based practice, clinical guidelines, standards, risk management and good practice has raised awareness of quality improvement and pa
16、tient safety. Assessment and monitoring have become regular features of the healthcare landscape. The development of the Generic Standards (2002) and Clinical Governance and Risk Management Standards (NHS QIS 2005) have provided a fairly constant focus on the key elements of clinical governance and
17、quality improvement activity: ongoing quality improvement based on evidence of good practice management of risk particularly with regard to patient safety staff development and support patient-focus public involvement What is Nursing Audit?IntroductionThe use of the term Audit is similar to that use
18、d to scrutinise financial practices and is a centrally driven process to analyse systematically clinical practices relevant to nursing. This scrutiny involves: Current and past practices Comparison of actual practice with an agreed standard Compares different types of practices for best use of resou
19、rces Encourages defensivenessDefinitionNursing audit is defined as:.part of the cycle of quality assurance. It incorporates the systematic and critical analysis by nurses, midwives and health visitors, in conjunction with other staff, of the planning, delivery and evaluation of nursing and midwifery
20、 care, in terms of their use of resources and the outcomes for patients/clients, and introduces appropriate change in response to that analysis (NHS ME, 1991 Framework for Audit for Nursing Services).In other words, nursing audit is the systematic evaluation of nursing which results in an improvemen
21、t in the quality of patient care.Audit versus ResearchAudit uses research methods; is not research, but the evaluation of evidenced based practice. Table 1 provides a basic breakdown of the differences between audit and research.AuditResearchIs not randomisedMay be randomisedCompares actual performa
22、nce against standardsIdentifies the best approach, and thus the sets the standardsConducted by those providing the serviceNot necessarily provided by those providing the serviceUsually led by service providersUsually initiated by researchersDoes not involve investigation of new treatments, but evalu
23、ates the use of current treatmentsInvolves comparators between new treatments and placebosInvolves review of records by those entitled to access themRequires access by those not normally entitled to access themEthical consent not normally requiredMust have ethical consentResults usually not transfer
24、ableResults may be generalisableHypothesis used to generate the standardTestable hypothesis generatedCompares performance against the standardPresents clear conclusionsTable 1: The differences between audit and researchThe Audit CycleTypes of audit1. Organisational audit2. Peer reviewCommon approach
25、es1. Prospective review2. Concurrent review3. Retrospective reviewAudit is a form of peer review and involves a cycle of activity as given below.Measure selected topicReview against standardIdentify gapsDecide actionImplement actionReview standardsThe Audit CycleFigure 1 the Audit CycleStep 1: Defin
26、e the Standard (Donabedian 1966)Standards comprise two elements that define the context for care and a third which shows how care is delivered. Structure environmental elements required to deliver care. E.g. policy, procedures, clinic setting, equipment, record keeping system etc. Process profession
27、al elements required to deliver care. E.g. KSF, SIGN guidance, Outcome measurable elements demonstrating results of care. E.g. Leg ulcer healing time, breast feeding duration, immunisation levels, smoking cessation, dying at home, asthma/diabetic stability, pressure ulcer prevalence etc.The elements
28、 contain criteria, which should be Reliable, Understandable, Measurable, Behaviourable and Acceptable (Kitson et al. 1990).Questions to ask What is the context for the delivery of this care? What organisational changes are required to respond to new policy? Are there clinical protocols available? Wh
29、at are the desired outcomes?Step 2: Measure current practice within the selected topic A baseline enquiry is carried out to identify problems requiring a solution to improve the quality of patient care.Questions to ask What is thought in the literature to be good practice in this area? What knowledg
30、e and skills are required for this role? Should consumers be involved? How do we measure value for money?Data collection methodsThese might involve: Interviews management/professional/patient face to face interview, telephone interview, focus group interview Questionnaire survey staff /patients/comm
31、unity Reflective Diaries Workload/caseload statistics and analysis, time of visit, number visits, care packages etc. Clinical indicators length of wound healing, breastfeeding rates, HEAT targetsStep 3: Identify gaps in service provisionQuestions to ask What are the reasons for not meeting the stand
32、ard? How can the service be improved?Step 4: Implement actionThis is the hardest area to address and involves the input from the whole team.An action plan needs to be developed.Step 5: Review standards If the standard is easily met, does it need to be raised? Is the standard too high? What are the f
33、uture needs?ReferencesDonabedian A (1986) Criteria and standards for quality monitoring. Quality Review Bulletin 12 (3): 99-100Kitson A, Hyndman S, Harvey G and Yerrell P (1990) Quality Patient Care: The Dynamic Standard Setting System London: Scutari PressMalby R (1995) Clinical audit for nurses and therapists.London: Scutari PressNHS e-library http:/www.elib.scot.nhs.uk/portal/elib/pages/index.aspx?referer=AAS&un=nousernameClinical governance website http:/www.clinicalgovernance.scot.nhs.uk/6