3.3 OUR KEY ACHIEVEMENTS IN 2021/22
3.3.1 CLINICAL, QUALITY ASSURING, & PATIENT SAFETY AUDITING Clinical audit is undertaken to systematically review the care that the Trust provides to patients against best practice standards and is an essential activity to take actions to improve the care provided. In 2021-22 we have conducted audits which evaluates the quality and safety of services across infection control, safeguarding, administrative, information governance, and quality assurance. Examples of some of the audit activity is listed below in Table 1, relevant to the services we provide. The way in which audits are presented provides a clear and concise method, benchmarks of standards, outcomes of the audit, and action plans put in place when required. These are all agreed and validated by the service and clinical leads who then presents them to the Quality Committee monthly.
The number of clinical and administrative audits carried out in 2021/22: 27
Table 1
Service
Standard Area
Audit Aim
Date
Outcomes: Key findings
Recommandations, changes, comment, or improvements
Criteria 1 - The process for the storage and provision of Emergency Drugs and resuscitation equipment at the IA hubs is clear to all Practices. 100 % compliant. Criteria 2 - All 4 sites had emergency equipment in line with the recommendations and was readily available in one place. 75 % compliant. Criteria 3 - All 4 sites had emergency equipment readily available in one place. Awaiting confirmation of weekly checks from Site 1. 100 % compliant. Criteria 4 - All 4 sites have completed risk assessments in the areas of legionella, PAT testing, Fire RA, Cleaning schedules and audits and IPC audits are being chased from sites 1, 2, and 3. 25 % compliant. This audit demonstrated an overall 90% compliance with the standards set in each of the 8 criteria’s (previously 72.5%, 83%, & 72%). Therefore, this demonstrates some success in the ongoing training and education programme, and the implementation plans of 1:1 clinical supervision. The implementation of both of those elements were based on the results of the 2 nd re-audit, and the results of the 3 rd re-
Improved Access & Enhanced Access (IA/EA)
Quality Assurance & Patient Safety
The audit is designed to measure compliance against criteria set from the CQC recommended set of emergency drugs and equipment which should be available at GP practices, H&S, and IP&C standards at all 6 IA hubs.
04- 05.2021, undertaken quarterly
The QA visits to continue 4-6 weekly until such time as the hubs are 100% compliant. Outcome: Achieved over the period of 08-12.2021
Enhanced Care Home Team (ECHT)
Quality Assurance & Patient Safety
This ongoing audit is designed to demonstrate compliance with good governance in documentation of consultations and to facilitate the identification of any further ongoing training needs.
06.2021, undertaken quarterly
Lessons learned from this is that the re-audit has clearly demonstrated that to provide regular, ongoing support, targeted teaching, clinical supervision does go some way to improve the outcomes and quality of the ECHT’s the quality of their consultation documentation. Outcome: Bespoke teaching and education programme is continually reviewed to meet the needs of the team. Clinical supervision sessions continue to be integral to the support given to the team.
audit clearly demonstrates some measurable success in those plans.
NNPC Quality Account 2021/22
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