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Title of audit (project number)

Speciality:
Division:
Project team
Name of project
lead
Title/grade: Insert title / grade here Data
period:
Specify time period
Other members of
project team
Title/grade: Insert title / grade here
Other members of
project team
Title/grade: Insert title / grade here Report
completion:
Insert date of report
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age 1 of 10
Clinical udit Report
Title of audit (project number)
Contents
)*ecuti%e summary 2
+ac,ground
Objecti%es
-ey findings
Recommendations
Clinical audit report
!roject title
Di%ision
Specialty
Disciplines in%ol%ed
!roject lead
Other staff members in%ol%ed
+ac,ground
Objecti%es
Standards
Sample
Data source
udit type
.ethodology
Results
Conclusions
!resentation/discussion
Recommendations
Clinical audit action plan
ppendi! 1: udit "easures
ppendi! 2: udit Proforma
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age 2 of 10
#!ecutive Summary
$ac%&round
+riefly describe the reasons for underta,ing the audit" This should include a reference to at
least one of the reasons for choice of audit listed on page ' of the Clinical udit !roposal
(orm"
'bjectives
This should be a statement of /hat you are trying to achie%e by underta,ing the audit and
should reflect a commitment to impro%e practice" Objecti%es should be S.RT 0specific1
measurable1 achie%able1 realistic1 timely2"
(ey findin&s
This section should report on the compliance against each of the audit standards" 3se the
table belo/ to list the standards and percentage compliance"
Standard Compliance
Colour code the compliance achie%ed /ith the ,ey belo/" 3sing a 4traffic light5 colour
scheme is a simple /ay of informing the reader of areas of good practice and areas for
impro%ement" The thresholds can be adjusted to suit a particular project1 pro%ided all
sta,eholders agree1 but the follo/ing is recommended as a guide"
(ey: dherence
6 7&8
dherence
9&8 : ;<8
dherence
= ><8
)ecommendations
Recommendations should be made based on the audit findings" In particular it should focus
on addressing any areas of non?compliance 0identified as red or amber2"
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age * of 10
Clinical audit report
Project title
)nter project title here"
Division
e"g" .edicine1 Surgery1 Speciality
Specialty
e"g" @eneral Surgery1 Oncology/Aaematology1 Trust?/ide
Disciplines involved
e"g" Nurses1 .edics1 llied Aealth !rofessionals
Project lead
State the full name1 title and department of the designated project lead 0the person /ith
o%erall responsibility for the project2"
't+er staff members involved
Bist full names and titles of those in%ol%ed and state their in%ol%ement in the clinical audit
e"g" data collection1 presentation etc"
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age , of 10
$ac%&round
+riefly describe the reasons for underta,ing the audit" This should include a reference to at
least one of the reasons for choice of audit listed on page ' of the Clinical udit !roposal
(orm"
'bjectives
This should be a statement of /hat you are trying to achie%e by underta,ing the audit and
should reflect a commitment to impro%e practice" Objecti%es should be S.RT 0specific1
measurable1 achie%able1 realistic1 timely2"
Standards
State /hat standards and guidelines you are comparing practice againstC !lease specify the
full title1 reference and source of the criteria" lso include a lin, to ppendi* ': the audit
measures /ritten for the audit 0page D of the Clinical udit !roposal (orm2"
e.g. NICE (January 2010). Clinical Guideline 92: Venous thro!oe!olis "
reducing the ris#. $lease see %&&endi' I (or a list o( the audit easures used in
this audit.
Sample
Ehich patients are you identifying and from /hich time period has the sample been
selectedC
e"g" ll patients that /ere admitted to the R3A bet/een Fanuary and (ebruary
#&'&"
Specify the total sample siGe/population and detail ho/ you achie%ed the sample selected for
clinical audit purposes 0methods2" e"g" inclusion/e*clusion criteria1 random sample1 stratified
sample etc"
e"g" There /ere a total of D&&& patients admitted to the R3A during the data
collection period" random sample of '&& patients /as chosen"
Data source
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age - of 10
Specify /here the data /as obtained from" )"g" !atient clinical notes1 *?rays1 patient sur%ey1
computer records" Ehere applicable also identify the ICD'& codes that /ere used to get a
list of patients /ith a particular diagnosis"
e"g" !atients /ith a primary diagnosis of stro,e /ere identified using ICD'&
codes I9'1 I9$ or I9D"
udit type
Specify if your clinical audit is criterion1 indicator?based1 patient sur%ey1 etc" If you are unsure
of the audit type please contact the Clinical udit Department for ad%ice"
"et+odolo&y
Specify if the clinical audit is national1 regional1 local or trust?/ide" Describe ho/ the clinical
audit /as underta,en" This should be /ritten in narrati%e format and include the follo/ing:
Ao/ the data collection tool /as de%eloped and /hether this /as piloted 0include a
copy of the audit tool in ppendi* #2
Data collection" Describe /hether the data collected /as retrospecti%e or concurrent1
ho/ the data /as obtained1 /ho collected the data1 /here the data /as collected1
/hether the data collected /as %alidated
Data analysis" Specify the computer pac,ages that /ere used to analyse the data
0e"g" .S )*cel1 S!SS etc"2
)esults
Initially state your 4N5 numberH N represents the total number of cases identified as the
representati%e sample 0audit population2 for inclusion in the clinical audit" e"g" '&& cases
/ere identified for inclusion in the audit"
The results section should report on the compliance against each of the standards / audit
measures that you are comparing your practice against 0these should be the standards you
listed on page D of the Clinical udit !roposal (orm2" This should include the number of
cases that /ere compliant and the percentage compliance" There should be further
in%estigation / e*planation of /here any non?compliance has been identified"
Ehen reporting on the standards the 4N5 number may %ary depending on the number of
patients that each of the standards is applicable to" (or each standard audited1 state the
number of patients that /ere applicable1 recorded as 4n"5
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age . of 10
!resent data in table format /here possible 0this is usually sufficient for most clinical audits2"
#/&/ Standard: T+e follo0in& vital si&ns s+ould be recorded on admission (12-1):
Criteria
Compliance
n (%)
)eart rate *0 (9+,)
-es&iratory rate *0 (9+,)
.e&erature /+ (9/,)
0lood &ressure /* (++,)
+e selecti%e /ith the use of charts1 remembering to use the most appropriate method to
present the data e"g" pie charts to sho/ proportions and bar charts for easy comparison
bet/een different areas/time periods"
!atient identifiable data e"g" surname1 date of birth1 NAS number1 hospital number etc"
should ne%er be included in a clinical audit report1 please refer to Caldicott Principles 2
and *"
Conclusions
The conclusions should summarise the ,ey findings from your results" This should identify
the areas of good practice /here standards are being met and identify the areas for
impro%ement /here there is a gap in compliance"
Presentation3discussion
dd in details of /here the audit /as presented and any actions that /ere agreed from the
meeting"
)ecommendations
Recommendations should be made based on the audit findings focusing on addressing any
areas of non?compliance identified" Incorporate S.RT 0Specific .easurable chie%able
Realistic Timely2 principles in all recommendations"
ll recommendations in the clinical audit report should be numbered and mirrored in the
action plan"
)"g" '" +y $'st .ay #&&71 the lead consultant for fractured nec, of femur /ill ha%e
updated the local guidelines for the management of fracture nec, of femur
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age 4 of 10
patients to include standards for the transfer of patients from the )mergency
Department to the Orthopaedic Eard /ithin # hours of arri%al"
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age 5 of 10
Clinical udit ction Plan
Project title Title of audit 0project number2
ction plan lead Name: Title: Contact:
)nsure that the recommendations detailed in the action plan mirror those recorded in the 4Recommendations5 section of the report" The 4ctions reIuired5 should specifically
state /hat needs to be done to achie%e the recommendation" ll updates to the action plan should be included in the 4Comments5 section"
)ecommendation ctions re6uired (s&eci(y 1None23
i( none re4uired)
ction by date Person
responsible
(Nae and grade)
Comments3action status
($ro5ide e'a&les o( action in &rogress3
changes in &ractices3 &ro!les
encountered in (acilitating change3
reasons 6hy recoendation has not
!een actioned etc.)
C+an&e sta&e
0see -ey2
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age 7 of 10
!roject Number:
(#8 (C+an&e status)
' Recommendation agreed but not yet actioned
# ction in progress
$ Recommendation fully implemented
D Recommendation ne%er actioned 0please state reasons2
> Other 0please pro%ide supporting information2
ppendi! 9: Standard Statements 3 udit "easures
1umber
#vidence of 6uality of care or service
(criterion)
Standard
(:
compliance)
#!ception(s) Definitions and instructions for data collection
Document name: Clinical udit !olicy Ref": #$#
Issue date: No%ember #&'& Status: (inal
!age 10 of 10

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