HI18.2010 Facilitate the clinical audit process

Overview

This standard is about facilitating the clinical audit process. It covers the technical support that is provided to individuals and teams who are responsible for carrying out audits. Individuals and teams may include clinicians and/or non-clinicians. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. the relevant legislation, policies, procedures, codes of practice and guidelines in relation to clinical audit
2. the professional codes of ethics relevant to your work, including those of other professions you are working with
3. the health and business context for data, information and knowledge requirements
4. the care delivery process in the area of work you are focussing your attention on
5. the organisational requirements for on-going audit programmes
6. the importance of effective information governance including; confidentiality, consent, data protection, security and privacy
7. the different ways in which data, information and knowledge are used in care
8. the information systems used in your organisation
9. current developments in the application of systems relevant to your work
10. the ways in which clinicians and other users interact with systems
11. the types of clinical audits there may be in your area of practice
12. how service and quality improvement work is initiated and how to make links with those staff and projects
13. the ways in which clinicians and non-clinicians are appointed or volunteer as auditors
14. the use of clinical audit methodologies
15. the roles of individuals and teams responsible for carrying out audits
16. the support which you can provide to individuals and teams responsible for carrying out audits
17. the limitations of the audit process
18. the importance of discussing and clarifying audit recommendations and resulting action plans
19. the types of conflicts which may occur due to audit recommendations and how these should be handled
20. the difference between audit and research
21. how to identify best practice based on evidence (clinical effectiveness)
22. how clinical audit should lead to improvement in healthcare practice
23. the reasons why it is necessary to identify risks involved in audit recommendations

Performance Criteria

You must be able to do the following:

1. support individuals and teams responsible for carrying out clinical audits to identify and prioritise the focus of the work
2. support individuals and teams responsible for carrying out clinical audits to agree audit standards based on recognised best practice
3. establish and agree the design of the clinical audit project with the audit lead, including an appropriate sample size and data collection process
4. help individuals and teams responsible for carrying out clinical audits to locate, abstract and analyse the audit data
5. where necessary, undertake agreed aspects of the clinical audit process on behalf of the individuals and teams responsible for carrying out clinical audits
6. support individuals and teams responsible for carrying out clinical audits to present or otherwise disseminate the audit findings to relevant persons
7. support individuals and teams responsible for carrying out clinical audits to formulate and implement an action plan to improve practice based on the findings of the audit
8. support individuals and teams responsible for carrying out clinical audits to produce a final report and implement recommendations
9. support individuals and teams responsible for carrying out clinical audits to re-audit as part of the continuous audit process

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: Core 5 Quality