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CHS19/166

Canberra Health ServicesOperational GuidelineClinical Audit Program

Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 3

Section 1 – Context...................................................................................................................3

Section 2 – Quality Assurance...................................................................................................3

Section 3 – Clinical Audit Definition..........................................................................................4

Section 4 – Clinical Audit Schedule...........................................................................................5

Section 5 – Clinical Audit Frequency.........................................................................................6

Section 6 – Clinical Audit Tools.................................................................................................6

Section 7 – Auditor Training......................................................................................................7

Section 8 – Conducting Clinical Audits......................................................................................7

Section 9 – Clinical Audit Reporting..........................................................................................9

Section 10 – Responding to Clinical Audit Results.....................................................................9

Section 11 – Use of Data.........................................................................................................11

Section 12 - Roles and Responsibilities...................................................................................12

Evaluation............................................................................................................................... 16

Related Policies, Procedures, Guidelines and Legislation.......................................................16

References.............................................................................................................................. 17

Definitions...............................................................................................................................18

Search Terms.......................................................................................................................... 18

Doc Number Version Issued Review Date Area Responsible PageCHS19/166 1.0 15/10/2019 01/10/2022 QSII 1 of 18

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

Use of data for

improvement - business as

usual

Right audit, right auditor, right time, right location

Right analysis and interpretation of audit results over time

Right people within CHS monitoring and reviewing clinical audit results and being accountable for improvement action when a gap is identified - including consideration of other data sources and information to support identification of potential areas for improvement

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Guideline Statement

The Clinical Audit Program Guideline has been developed to document the purpose, intent and governance of quality assurance, reporting and evaluation processes for the Canberra Health Services (CHS) clinical audit program. This program: monitors the safety and quality of care provided focuses on staff learning opportunities identifies and supports immediate action which will improve patient care uses data to identify and inform CHS Division, National Standard Committee or

organisation wide improvement action required to ensure person-centred, safe, quality and effective care

provides a framework for monitoring and reporting on audit results with a process for escalation of potential patient safety risks and monitoring improvement action taken by accountable person(s).

Key ObjectiveA key objective of this guideline is to support a positive clinical audit culture across CHS so that clinical audits that monitor the safety and quality of care provided are seen as: everyone’s responsibility – supports disciplines working together to deliver patient care

as a team meaningful – demonstrating that the care we provide is consistently person-centred,

safe, quality and effective care a positive learning opportunity – identifying immediate action (where applicable) which

will improve patient care part of everyday business – demonstrating that the care we provide consistently

complies with best-evidence based practice and standards requirements.

Figure 1: Visual representation of use of data for improvement – business as usual Back to Table of Contents



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Scope

This guideline applies to all staff working at Canberra Health Services.

This guideline only applies to clinical audits included in the CHS clinical audit program.

Back to Table of Contents

Section 1 – Context

This guideline is informed by the: Canberra Health Services Vision: Creating exceptional health care together ACT Health Quality Strategy National Safety and Quality in Health Services Standards (National Standards) and Australian Commission on Safety and Quality in Health Care: The Assessment

Framework for Safety and Quality Systems Manual, June 2018 (Manual).

The Manual outlines the PICMoRS Method, a structured assessment method to assist with assessing compliance against the requirements of the National Standards. This Guideline has been structured to align with the PICMoRS Method which consists of:

P – ProcessI – Improvement strategiesC – Consumer participationMo – Monitoring R – ReportingS – Safety and quality systems.


Section 2 – Quality Assurance

For the purpose of this guideline, CHS defines quality assurance as the process by which the clinical performance of CHS measured and compared against best-evidence based practice and National Standards requirements.

The aim of quality assurance is to provide confidence and assurance that the care provided to our community is person-centred, evidence-based, high quality, safe and effective. Quality assurance mechanisms include clinical audit, staff surveys, patient surveys, reported patient outcomes and feedback.



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Figure 2: Visual representation of CHS Quality Assurance definition

Figure 3: Visual representation of CHS Quality Assurance Process


Section 3 – Clinical Audit Definition

CHS defines clinical audit as the systematic measurement and monitoring of care processes and systems against agreed best-evidence based practice, standards requirements and CHS policies and procedures.

Clinical audit is an essential component of quality assurance and a key mechanism to monitor the delivery of person-centred, safe and effective care, and review results to identify if improvement action is required.

Clinical audits should be conducted transparently, with clear communication, and with a focus on improving the delivery of care and positive patient outcomes. It is not intended that



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clinical audits are used for punitive purposes, nor as a substitute for ongoing quality control activities or in place of clinician/staff performance management frameworks.

Developing or conducting an audit is not in itself a quality improvement activity. However, audit can be used to inform measurement for a quality improvement activity. For further information on quality improvement processes, please email [email protected].


Section 4 – Clinical Audit Schedule

The CHS clinical audit program has a CHS Clinical Audit Schedule which includes: mandatory clinical audits which measure clinical performance against National Standards

and CHS policy/procedure requirements – these may be organisation wide or area specific, and

clinical audits which measure clinical performance against best-evidence based practice and standards requirements, or to monitor a patient safety risk identified by patients or the organisation and based upon the consensus of clinical experts – these may be organisation wide, Division or area specific.

The CHS Clinical Audit Schedule is informed by organisation and divisional safety and quality priorities and includes consideration of the following: ACT Health Quality Strategy priorities National priorities and requirements e.g. outlined in Clinical Care Standards, Australian

Atlas of Healthcare Variation, National Standards International priorities e.g. set out by the World Health Organisation Organisation and division priorities e.g. outlined in best-evidence based practice and CHS

policies/procedures.

The CHS Clinical Audit Schedule will be available from the Quality Assurance intranet site. This schedule does not include all audits undertaken across CHS. Areas/Divisions may be required to undertake other audits not contained within the clinical audit schedule to demonstrate compliance with CHS policy/procedure, best-evidence based practice and standards requirements.

The CHS Clinical Audit Schedule is reviewed and then endorsed annually by the Health Services Executive Committee or sooner if identified by the relevant National Standard Committee, Division Safety and Quality Committee or clinical experts.

It is at the discretion of the Health Services Executive Committee as to whether an audit included in the CHS Clinical Audit Schedule may be ceased if sustained acceptable results have been achieved.


Section 5 – Clinical Audit Frequency



mailto:[email protected]

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Evidence on recommended clinical audit frequencies is lacking within the current literature. The clinical audit frequencies set out in the CHS Clinical Audit Schedule have been established considering: input by the relevant governance committee, either a National Standard Committee or a

Division Safety and Quality Committee input by clinical experts (where available) the volume of audits required within respective areas previous audit results within respective areas operational resourcing availability.

All requests to amend a clinical audit frequency as set out in the CHS Clinical Audit Schedule must be submitted to [email protected].

Please refer to Section 10 – Responding to Clinical Audit Results for further details.


Section 6 – Clinical Audit Tools

Quality, Safety, Innovation and Improvement (QSII) is responsible for the preparation and development of clinical audits which monitor the safety and quality of care provided to our patients as part of the CHS clinical audit program.

Clinical audit tools are developed in consultation with clinical experts from across CHS community and hospital-based services. When being developed there is a clear plan for collecting data, including ‘who, what, where, when, how, how many and by whom?’ These audit tools are then tested to ensure they are fit for purpose and are endorsed by the relevant National Standard Committee or Division Safety and Quality Committee.

CHS reviews clinical audit tools on an annual basis or sooner if a need is identified by the relevant National Standard Committee, CHS Division or clinical experts.

Clinical audit tools may require amendment due to changes in CHS policy/procedure, legislative requirements, organisation, national and/or international priorities and changes to best-evidence based practice.

All requests to amend a clinical audit form must be submitted to [email protected].


Section 7 – Auditor Training

QSII is responsible for facilitating auditor training. This training includes: how to conduct an audit using the audit device





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the purpose and intent of clinical audit overview of the clinical audit program and related audits the new audit tools, audit platform and audit device loan process information to be provided to patients when a clinical audit is conducted how to respond to patient safety risks and provide feedback at the time of audit.

For further information on the clinical audit platform device and auditor training please email [email protected].


Section 8 – Conducting Clinical Audits

Note:For any clinical audits conducted involving a patient or consumer (e.g. at a patient’s bedside), the auditor must introduce themselves, and inform the patient and their family and/or carer (if present) of the purpose of the audit. If any issues are raised, the auditor should liaise with the manager of the area before conducting the audit.

Prior to conducting a clinical audit included in the CHS clinical audit program, please ensure that you have contacted QSII by emailing [email protected] . QSII can help facilitate auditor training (if required) and loan you an audit device.

Sample Size Since clinical audit is not conducted for research purposes the sample sizes for clinical audits are generally informed by the resourcing available and the degree of confidence/belief required in the statistical validity of the results.

Guidance on recommended sample sizes for clinical audits is currently lacking in the literature. CHS considers that to make a defensible case for action, a reasonable minimum sample size for clinical audits per audit cycle is: ten (10) patients per inpatient clinical area* five (5) patients per community based area.

* informed by Cairns and Hinterland Hospital and Health Services Clinical Audit Procedure Version 2.0 and Clinical Audit Schedules.

Should an alternate sample size be considered necessary, please discuss this with QSII by emailing [email protected].

Approval of alternate sample sizes will need to be negotiated on case-by-case basis with the relevant National Standard Committee or Division Safety and Quality Committee, and QSII.

Please see below for some factors to consider in relation to alternate sample sizes: anticipated frequency of the audit






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anticipated volume of patients of the area total number of audits already completed by the area.

Considerations for CHS DivisionsTo assist with clinical audit result reliability and support working together to provide exceptional patient care, QSII recommends that CHS Divisions actively encourage clinical audits being undertaken by staff from another clinical area e.g. clinical area ‘x’ staff auditing clinical area ‘y’ staff and vice versa. If this is not possible for operational reasons, the reliability of the clinical audit results may be of a lesser quality.

It is also strongly recommended that CHS Divisions consider the following: Identifying clinical auditors from nursing/midwifery, allied health and medical disciplines

(at a minimum) to support clinical audit engagement by staff across disciplines Ensuring that clinical auditors undertake auditor training provided by QSII and have had

some prior exposure to the clinical areas in which they will be auditing Identifying Clinical Audit Champions from nursing/midwifery, allied health and medical

disciplines (at a minimum) from across the Division to support clinical audit engagement within their Division. Clinical Audit Champions play a key role in promoting and embedding a sustainable, positive clinical audit culture. These individuals should ideally be passionate about delivering person-centred, safe and effective care and looking for further opportunities to improve patient care in their clinical area and beyond. Clinical Audit Champions are needed at different levels and should include nursing/midwifery, allied health, medical and administrative staff if possible.

Driving immediate improvements at time of auditWhen undertaking an audit, the auditor must use this as an opportunity to drive immediate patient care improvement i.e. if while conducting an audit the auditor witnesses a colleague not following all the steps of the process, they should educate their colleague on correct process to follow at the time of audit.

This is an essential component of the CHS clinical audit program and is underpinned by the literature which indicates that audit and feedback often contributes to potentially important, but small improvements.

Responding to Patient Safety Issues identified at time of auditThe clinical audit tools provide specific guidance on what constitutes a patient safety issue. If a patient safety issue is identified at the time of audit, the auditor must escalate the issue to the area’s Clinical Nurse Consultant/Clinical Midwife Consultant or Unit Manager and submit a clinical incident report into the clinical incident notification system (RiskMan) when specified as a requirement in the clinical audit tool.

Examples of patient safety issues include: Assessing Central Venous Access Device in situ and there is no date on the patient

dressing



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Assessing IV Cannula in situ and date on the IVC dressing is outside of dwell time (72 hours).


Section 9 – Clinical Audit Reporting

QSII is responsible for undertaking audit validation, data analysis of clinical audit results and providing quality assurance reports (which includes reporting of other safety and quality data), across CHS to help inform monitoring and trended analysis of clinical performance, including identification of gaps. The quality assurance reports are tabled for consideration and action (where required) at the highest level of CHS governance, the Health Services Executive Committee (HSEC), in addition to other key governing committees e.g. National Standards and Division Safety and Quality Committees.

Reporting within CHS DivisionsDivision Executive Directors are responsible for ensuring that clinical audit results are communicated to staff within their Divisions with an explanation of what the audit results indicate (based upon the quality assurance reports provided), including whether any specific improvement action is required to address gaps.

Divisions are strongly encouraged to table all clinical audit results at their Division Safety and Quality Meeting and ensure that results are distributed to clinical areas and that improvement actions are reported back to their Division Safety and Quality Committee.


Section 10 – Responding to Clinical Audit Results

The performance indicators* below have been developed to support a consistent CHS wide approach when responding to clinical audit results:

Performing On Target 80 – 100% audit result

Performance Within agreed tolerance range 51 – 79% audit result

Not Performing Outside agreed tolerance range 0 – 50% audit result OR51 – 79% audit result over three or more auditing cycles

* informed by the Austin Health Quality Management Framework version 3.1.



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QSII will: consult with the relevant National Standard Executive Sponsor or Division Executive

Director prior to assigning responsibility for addressing any gap found between current process and best practice in the audit results e.g. in the event of a Performance Flag or Not Performing Flag.

notify the relevant National Standard Executive Sponsor or Division Executive Director in the event of a Not Performing Flag within seven working days of audit result validation

consult with the relevant National Standard Committee or Division Safety and Quality Committee and clinical experts to identify whether a clinical audit with a Performing Flag result over three or more auditing cycles should have its frequency further reduced.

In the event of a Performance Flag Division Safety and Quality Committee/National Standard Committee (governing

committee) to review audit results and consider improvement action required to address the gap. Consultation with other stakeholders may also be required e.g. clinical areas

If the governing committee identifies that: o further assistance is required, QSII is available to support triangulation of data

options, providing full data sets (where available) and identifying clinical experts to help address any gaps

o a quality improvement activity may be required, please refer to the QI intranet site for guidance on how to commence a quality improvement activity. For further information on how QSII can support the initiation and management of this process, please email [email protected]

Governing committee to provide update to QSII on the improvement action taken to address the gap. This update should include minutes of meetings where audit results and any associated challenges/barriers are discussed, along with improvement plans developed

QSII will arrange for updates to inform HSEC with briefings on the status of improvement action taken to address gaps

Once the gap has been addressed, QSII will negotiate with the governing committee to determine the frequency of the next audit round to provide assurance that the gap has been resolved

If the gap is not resolved (or does not appear to be progressing) within three months, QSII will negotiate with the governing committee to determine whether the gap needs to be escalated to HSEC for further consideration.

In the event of a Not Performing Flag QSII to notify Division Executive Director/National Standard Executive Sponsor of the

need to address a gap. This may include suggestions to support improvement action being taken. Consultation with other stakeholders may also be required e.g. clinical areas

Division Executive Director/National Standard Executive Sponsor in consultation with relevant governing committee to consider improvement action required to address the gap

If the governing committee identifies that:




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o the cause(s) of the gap are not readily identifiable a spot audit, with support from QSII may be undertaken to help identify the cause(s)

o further assistance is required, QSII is available to support triangulation of data options, providing full data sets (where available) and identifying clinical experts to help address any gaps

o a quality improvement activity may be required, please refer to the QI intranet site for guidance on how to commence a quality improvement activity. For further information, please email [email protected]

Division Executive Director/National Standard Executive Sponsor to provide an update to QSII on the improvement action being taken to address the gap. This update should include minutes of meetings where audit results and any associated challenges/barriers are discussed, along with improvement plans developed

QSII will arrange for an interim update to inform HSEC with briefings on the status of improvement action taken to address gaps

QSII will negotiate with the Division Executive Director/National Standard Executive Sponsor for a follow up audit within one to two months

Once the gap has been addressed, QSII will negotiate with the Division Executive Director/National Standard Executive Sponsor to determine the frequency of the next audit round to provide assurance that the gap has been resolved

If the gap is not resolved (or does not appear to be progressing) within three months, QSII will negotiate with the Division Executive Director/National Standard Executive Sponsor to determine whether the gap needs to be escalated to HSEC for further consideration.


Section 11 – Use of Data

Use of dataClinical audit data is for CHS internal use only. All clinical audit results must be treated and stored sensitively and in line with the requirements set out in relevant legislation, ACT Public Service Code of Conduct and CHS policies and procedures. Clinical audit data is not considered to be exempt from Freedom of Information requests.

Further assistance available QSII is available to provide general advice to CHS staff on clinical audits and area specific audit development. For further information, please email [email protected].

QSII is also available to assist with some data requests. Depending on the data required you may need to request this data from QSII or you may be referred to another area within CHS or the ACT Health Directorate to access the requested data. For further information, please email [email protected].







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Section 12 - Roles and Responsibilities

Role ResponsibilitiesHealth Services Executive Committee

Leading organisation wide decision making informed by clinical audit results relating to safety and quality of care

Leading a positive clinical audit culture across CHS Leading the review and monitoring of organisation wide

clinical audit results Identifying improvement actions required, including

assigning responsibility for these improvement actions Monitoring improvement action taken in relation to gaps Reviewing and endorsing the CHS Clinical Audit Schedule

National Standard Executive Sponsor

Leading the review and monitoring of clinical audit results relevant to their National Standard

Leading the development of improvement plans relevant to their National Standard

Leading and monitoring improvement action relevant to their National Standard

Ensuring the provision of regular updates to QSII on improvement action taken to address gaps

Leading a positive clinical audit culture within their National Standard Committee

National Standard Committees

Reviewing and monitoring of clinical audit results relevant to their National Standard

Developing improvement plans relevant to their National Standard, which may include assigning responsibility for these improvement actions

Ongoing monitoring of improvement action relevant to their National Standard, including the provision of regular updates to QSII

Contributing to the completion of assigned improvement actions

Supporting a positive clinical audit culture Providing expert advice on audit tool content Endorsing clinical audit tools relevant to their National

Standard

Division Executive Directors

Communicating audit results across their Division Leading the review and monitoring of clinical audit results

relevant to their Division Leading a positive clinical audit culture Ensuring that areas in their Division complete clinical audits



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as set out in the CHS Clinical Audit Schedule Once notified by QSII, following up with areas whose audit

results are not submitted as scheduled. This may require support from the Division’s Clinical Audit Champions to address

Leading the development of improvement plans relevant to their Division

Leading and monitoring improvement action relevant to their Division

Ensuring the provision of regular updates to QSII on improvement action taken to address gaps

Division Safety and Quality Committees

Active involvement in the review and monitoring of clinical audit results relevant to their Division – these are contained within quality assurance reports provided by QSII

Developing improvement plans relevant to their Division, which may include assigning responsibility for these improvement actions

Ongoing monitoring of improvement action relevant to their Division, including the provision of regular updates to QSII

Contributing to the completion of assigned improvement actions

Supporting a positive clinical audit culture Providing expert advice on audit tool content Supporting areas in their Division to complete clinical audits

as set out in the CHS Audit Schedule Endorsing clinical audit tools relevant to their Division

Managers/Supervisors Ensuring that their area completes audits as set out in the CHS Audit Schedule

Ensuring that staff receive auditor training facilitated by QSII prior to undertaking audits

Supporting staff to undertake clinical audits when required as set out in the CHS Clinical Audit Schedule and including assigning staff dedicated time to undertake these audits

Supporting staff to contribute to improvement action relevant to their area

Supporting staff to contribute to the development and testing of clinical audit tools

Supporting a positive clinical audit culture in their area Encouraging auditors to provide feedback to colleagues to

drive immediate improvements to patient care at the time of audit

Encouraging staff to use feedback provided by an auditor as a positive learning opportunity to further enhance the safety



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and quality of care provided to patients

Clinical Audit Champions

Promoting a positive culture of clinical audit by leading by example within their Division

Undertaking auditor training facilitated by QSII Promoting staff involvement in improvement action relevant

to their Division Communicating updates on improvement action taken to

address gaps within their Division Undertaking audits and providing informal support to other

auditors within their Division Promoting the review and monitoring of clinical audit results

relevant to their Division Communicating audit updates to their Division and liaising

between their Division and QSII Using the clinical audit platform device in accordance with

the auditor training provided, and returning the device to QSII upon audit round completion

Attending Clinical Audit Champion Forums facilitated by QSII

Please note: The time commitment required for a Clinical Audit Champion will vary depending upon the quantity and frequency of audits undertaken within their Division, though approximately eight hours per month may be initially required. This commitment is not required to be taken in one day and can be spread out across the month e.g. two hours per week.

CHS staff Undertaking auditor training facilitated by QSII with the approval of your manager/supervisor

Completing clinical audits as directed by your manager/supervisor – this may include undertaking audits in other areas within your Division

Immediately addressing any patient safety issues identified at the time of audit

When undertaking an audit, the auditor must use this as an opportunity to support staff learning opportunities and drive immediate improvements to patient care e.g. educating colleague on correct process to follow

Using feedback provided by an auditor as a positive learning opportunity to further enhance the safety and quality of care provided to patients

Contributing to the development and testing of clinical audit tools

Contributing to a positive clinical audit culture by being receptive to audit feedback and being actively involved in



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the review and monitoring of audit results Contributing to improvement action taken to address gaps

within their area Using the clinical audit platform device in accordance with

the auditor training provided, and returning the device to QSII upon audit round completion

Consumers Providing feedback during the developing and review of audit tools and processes, through consumer representation e.g. on National Standards Committees and working groups, Divisional Safety and Quality Committees

Providing feedback when clinical audits are undertaken

QSII Overseeing and monitoring the CHS clinical audit program, including developing, maintaining and reviewing clinical audits, and facilitating auditor training

Supporting Clinical Audit Champions, including promotion of the Clinical Audit Champion role and facilitating Clinical Audit Champion Forums

Managing allocation of the clinical audit platform devices which are provided to CHS staff on as required loan basis

Trouble shooting any issues associated with the clinical audit platform device

Supporting a positive culture of clinical audit through active engagement with staff across CHS

Developing and testing clinical audit tools, including liaison with areas to ensure clinical audit tools are fit for purpose

Maintenance of the CHS Clinical Audit Schedule (under development), coordinating and communicating audit schedule requirement across CHS. This includes advising Division Executive Directors if areas they are responsible for have not submitted audit results as scheduled

Providing accurate and timely quality assurance reports to governance committees and clinical area(s), including assigning responsibility for improvement action to address gaps

Providing additional assistance with the analysis and/or interpretation of results, triangulation of data, provision of full data sets and other data as required

Maintenance of the CHS Clinical Audit Action Register, including regular update template, HSEC briefings and escalation of gaps to HSEC for consideration in negotiation with the relevant National Standard Executive Sponsor or Division Executive Director

Maintenance of the CHS Clinical Audit Lessons Learned



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Register


Evaluation Consult with staff involved in clinical audits e.g. Clinical Audit Champions to identify any

variance from guideline and inform potential improvements to the clinical audit process Number of identified gaps closed as per clinical audit process Number of quality improvement activities commenced based upon clinical audit results.


Related Policies, Procedures, Guidelines and Legislation

Policies Consent and Treatment Internal Audit Policy

Procedures Clinical Records Documentation Internal Audit Procedure Incident Management Procedure

Standards National Safety and Quality in Health Services Standards

Guidelines ACT Health Quality Strategy ACT Public Service Code of Conduct Australian Commission on Safety and Quality in Health Care: The Assessment Framework

for Safety and Quality Systems Manual, June 2018

Legislation Health Records (Privacy and Access) Act 1997 Information Privacy Act 2014 Human Rights Act 2004 Freedom of Information Act 2016 Territory Records Act 2002 Health Act 1993 Mental Health Act 2015


References



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1. Duckett S, Cuddihy M & Newnham H, 2016, Targeting zero: supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care: report of the review of hospital safety and quality assurance in Victoria, Victorian Government Melbourne

2. Bullivant J & Corbett-Nolan A, 2010, Clinical audit: a simple guide for NHS Boards & partners, Healthcare Quality Improvement Partnership, Good Governance Institute

3. Scoville R, Little K, Rakover J, Luther K & Mate K, 2016, Sustaining Improvement IHI White Paper. Institute for Healthcare Improvement

4. The Institute of Internal Auditors (IIA) 2013 Position Paper: The three lines of defence in effective risk management and control

5. Gregor Henderson Limited, 2011, Developing a Quality Assurance Framework for Mental Health in Western Australia Final Report

6. Healthcare Improvement Scotland, 2017, Quality of Care Approach Quality assurance to drive improvement, NHS Scotland

7. Austin Health Quality Management Framework version 3.1 8. Sunshine Coast Hospital and Health Service Clinical Audit Governance

Framework 20169. Cairns and Hinterland Hospital and Health Services Clinical Governance Policy

Version 1.110. Cairns and Hinterland Hospital and Health Services Clinical Audit Procedure

Version 2.0 11. Quality and Patient Safety Directorate/National Director of Quality and Patient

Safety, 2017, A Practical Guide to Clinical Audit12. National Institute for Clinical Excellence (NICE), 2002, Principles for Best Practice

in Clinical Audit, Radcliffe Medical Press13. Healthcare Quality Improvement Partnership, 2016, Developing a Clinical Audit

Policy14. Kerber et al., 2015, Counting every stillbirth and neonatal death through

mortality audit to improve quality of care for every pregnant woman and her baby, BioMed Central Pregnancy and Childbirth

15. Paton J, Ranmal R & Dudley J, 2015, Clinical audit: still an important tool for improving healthcare, Archives of Disease in Childhood – Education and Practice

16. Ivers et al. 2012, Audit and feedback: effects on professional practice and healthcare outcomes (Review), Cochrane Database of Systematic Reviews

17. Healthcare Quality Improvement Partnership 2015, A guide to quality improvement methods

18. Sale, D 2000, Quality Assurance a pathway to excellence, Great Britain.


Definitions



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Clinical Audit: The systematic measurement and monitoring of care processes and systems against agreed best-evidence based practice, standards requirements and CHS policies and procedures.

The CHS definition of clinical audit has been developed based upon the following resources – National Institute for Clinical Excellence (NICE) Principles for Best Practice in Clinical Audit 2012, Cairns and Hinterland Hospital and Health Services Clinical Audit Procedure version 2 and Healthcare Quality Improvement Partnership 2015, A guide to quality improvement methods.

Quality Assurance: The process by which the clinical performance of Canberra Health Services is measured and compared against best-evidence based practice and standards requirements.

The CHS definition of quality assurance has been developed based upon the following resources – Ivers et al. 2012, cited in the Review of hospital safety and quality assurance in Victoria (Duckett Report), A Quality Assurance Framework for Mental Health in Western Australia, Healthcare Quality Improvement Partnership Developing a Clinical Audit Policy and NHS Scotland Quality of Care Approach: Quality assurance to drive improvement.


Search Terms

Clinical audit, audit, quality assurance, QA, National Standards, auditing, auditor, National Standard


Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval

This document supersedes the following: Document Number Document Name



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